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NORTHEASTERN 

UNIVERSITY 

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GIVEN IN MEMORY 

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DR. OTTO RAUBENHEIMER 



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MARY PUTNAM JACOBI, M.D. 

A PATHFINDER IN MEDICINE 



WITH SELECTIONS FROM HER WRITINGS 

AND 

A COMPLETE BIBLIOGRAPHY 



EDITED BY 
THE WOMEN'S MEDICAL ASSOCIATION 

OF 

NEW YORK CITY 



G.P.Putnam's Sons 
^^ewYork ^ London 

XThc IR-nickerbockeriPrega 
1925 



nn 

3"3 



Copyright^ i9£Sr 
by 
The Women's Medical Association of New York City, Inc. 



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Made in the United States of America 



To 
ELIZABETH BLACKWELL, M.D. 

"Among all the pioneer group of women physicians, hers 
chiefly deserves to be called the Record of an Heroic Life." 

Women in Medicine — Mary Putnam Jacobi, M.D. 



(14101 



FOREWORD 

The Women's Medical Association of New York City, desires 
to perpetuate the memory of the work done by one of its founders, 
one of the great pioneer women in medicine. She opened the 
doors of a great university that women might equally with men 
obtain a scientific medical education. All her life she was a 
zealous worker for this advancement of the medical education 
of women. To continue this, her work, the Association has 
founded the Mary Putnam Jacobi Memorial Fellowship, thus 
far awarded four times, to increase the medical knowledge of the 
recipients. The Association in this volume has collected some 
of her medical writings, illustrating her studies on the medical 
problems of her day. With her writings as with her other medi- 
cal work, "she was never satisfied. There was always a better 
than her best, a higher than her highest to be striven for; and 
ii this striving she was not influenced by personal ambition, but 
by the higher object — the truth to be attained." 



CONTENTS 

PAGE 

Foreword ........ xi 

Physician, Teacher, Author ..... xiii 

Member of Medical Societies .... xxviii 

Mary Putnam Jacobi ...... xxxi 

Letters to the Medical Record, 1867- 1870 — Medical 

Matters in Paris. Signed P. CM. . . . i 

Some Details in the Pathogeny of Pyemia and Sep- 
ticemia ........ 171 

Report of an Address to the Graduating Class of 
THE Woman's Medical College of the New York 
Infirmary ........ 201 

On Atropine ........ 204 

Pathogeny of Infantile Paralysis .... 240 

Remarks upon the Action of Nitrate of Silver on 

Epithelial and Gland Cells .... 284 

Sphygmographic Experiments upon a Human Brain, 

Exposed by an Opening in the Cranium . . 299 

Acute Fatty Degeneration of the New-Born . 311 



viii Contents 



PAGE 



Contribution to Sphygmography . . . .326 

Case of Facial and Palatine Paralysis, and Loss of 

Equilibrium, Produced by a Fall on the Head 329 

Inaugural Address at the Opening of the Woman's 
Medical College of the New York Infirmary, 
October i, 1880 .... . . 334 

Specialism in Medicine 357 

Shall Women Practice Medicine? .... 367 

An Address Delivered at the Commencement of the 
Woman's Medical College, of the N. Y. Infirm- 
ary, May 30, 1883 391 

Opening Lecture on Diseases of Children, at the 

Post- Graduate Medical School, New York . 403 



The Indication for Quinine in Pneumonia 
Case of Probable Tumor of the Pons 
The Practical Study of Biology 

Hysterical Fever 

Modern Female Invalidism 



419 
446 

458 
463 
478 



A Suggestion in Regard to Suggestive Therapeutics 483 

Address Before the Women's Medical Association 

About 1900 494 



Contents ix 



PAGE 



Description of the Early Symptoms of the Meningeal 
Tumor Compressing the Cerebellum, from WHipfi • 
THE Author Died. Written by Herself . . 501 

Bibliography 505 

Index 513 



MARY PUTNAM JACOBI 
A Pathfinder in Medicine 



MARY PUTNAM JACOBI 

PHYSICIAN, TEACHER, AUTHOR 

A diploma from the Female Medical College of Pennsylvania, 
in 1864, marked the entrance into the medical profession of Mary 
C. Putnam.' A year as interne in the New England Hospital 
followed.^ The desire for a medical education absolutely un- 
attainable in the United States, led her, as it has always led 
pioneers, "through tangled underwood of old traditions, out to 
broader ways," even to the doors of the Paris I'ficole de M^decine, 
to which women had not been admitted. The romantic story 
of this adventure, beginning in 1866, she relates in her letters 
from Paris to her beloved mother.^ She was the first woman 
to be admitted to the French school. Her thesis, written during 
the Siege of Paris in the Franco-Prussian War, received the 
bronze medal.'' 

' The Female Medical College of Pennsylvania was founded in 1850, 
"and after a long and precarious period of struggle, finally touched upon a 
solid basis of medical realities and thence began its prosperous modern career. " 

The title of the college was, in 1867, changed by decree of court to that 
of the Woman's Medical College of Pennsylvania. It is now (1924) the only 
medical college in the United States devoted exclusively to the education of 
women in medicine. 

' The New England Hospital, founded in 1862, the second hospital in the 
United States conducted by women ph^^sicians. 

3 Volume I, Letters. 

* The copy of the thesis in the New York Academy of Medicine, was 
presented to the New York Hospital Library, April 23, 1892, by Francis D. 
Buck, M.D., and passed to the Academy of Medicine with the library of the 
Society of the New York Hospital, March, 1898. 



xiv Mary Putnam Jacobi 

Returning to New York in September, 1871, with what Sir 
William Osier described as "a Paris medical degree and a training 
in scientific medicine unusual at that date even among men," 
she immediately opened an office in her father's house, 328 East 
15th Street, and began private practice. She entered at once 
into the professional life of the city, and joined in the discussions 
of those medical societies to which women were admitted.' The 
first such discussion seems to have been at a meeting of the 
Medical Library and Journal Association.^ It was before this 

News items, Med. Record, 1871 (September 15), page 335: 

Mary Putnam 

"Miss Putnam," says a Paris paper, "the young American who has for 
some 5'ears been following the course in Tficole de M6decine, submitted her 
graduating thesis to the Faculty. It was read in the large lecture room of 
the College before a numerous audience, and was received with warm com- 
mendation. The President of the Board of Examiners found it deserving of 
the highest note — 'extr^mement satisfait.' This mark is rarely given for a 
thesis. Miss Putnam has also received the highest mark at each of her five 
examinations. She was ready for graduation a year ago, but the war broke 
up the schools, and she has devoted the year to work in the hospitals. She is 
the first woman who obtained admission to I'ficole de M^decine, but not the 
first who graduated, as Miss Garret took a year's course and received her 
degree a year or more ago. She writes that one of the dedications of her 
thesis was as follows: 'To the professor, whose name I do not know, who 
alone voted in favor of my admission to the £cole, thus protesting against the 
prejudice that would exclude women from superior studies.' One of the 
professors on the board took up the dedication, read it aloud to the audience, 
and then defended himself from the accusations. He 'had never voted, 
he had no such prejudice, he did not believe that it existed in the faculty, etc., 
and he considered the claim for right to participate in the superior studies a 
most legitimate demand. ' 

" Miss Putnam writes: 'I confess I should not be sorry to have that part 
of the stance stereotyped for the benefit of New York schools of medicine." 

' First medical discussion found. Med. Record, vol. vi, page 448. Meet- 
ing of the Medical Library and Journal Association, October 27, 1871. The 
topic under discussion: The gj^mnastic treatment of chorea. 

"Doctor Mary C. Putnam, who had closely followed the clinic of the 
Hdpital des Enfants (rue de Sevres) for the last four years, replied to a ques- 
tion by Doctor Seguin that the gymnastic treatment was still regularly em- 
ployed there for all choreics able to be out of bed. The milder cases received 
also sulphuret of potassium baths! Those more severe arsenic! And the 
worst tartar emetic." 

' The Medical Library and Journal Association of New York, organized 
in 1864, to establish a medical reading room and to make the library a nucleus 



Physician, Teacher, Author xv 

Association that the young doctor read the first paper presented 
to a medical society , in the United States, by a medical woman. ^ 

Physician. 1871-1902 

"Honour a physician with the honour due unto him for the uses which ye 
may have of him: for the Lord hath created him. The Lord hath created 
medicines out of the Earth and he that is wise will not abhor them." (Ec- 
clesiasticus, Chapter 38.) 

The work of a large private practice, attendance at the 
dispensary and teaching in the college and in the hospital, made 
what she herself called a "busy day." A private patient said 
of her "that she was a physician dedicated to the work of helping 
her fellow-mortals." She was always ready at the moment of 
greatest necessity. 

When the doctor returned from Paris, there were but four 
hospitals in the United States where a woman was eligible as an 
attending physician.^ One dispensary, that of the New York 
Infirmary, offered her a position on its staff. ^ The Infirmary 
treated in its little hospital, the first year after the doctor's 
return from Paris, 144 patients, and this after circulars had been 
sent in the early part of the season to all clergymen and heads 
of benevolent societies, stating the nature of the cases received. '^ 
[These patients and those in private practice were studied withH 
the enthusiasm which was a marked characteristic of Dr. Mary 
Putnam Jacobi. One of the first patients presented an unusual 
deformity of the heart and this was shown at the New York Path- 



for a club room. "Stated reunions " were held every Friday evening. "First 
class papers are read followed by profitable discussions. The Constitutions 
for 1864 defines those physicians eligible for membership as "any regular and 
reputable medical man." The Constitution for 1865 omits the word "man" 
and the doctors Elizabeth and Emily Blackwell were admitted to membership. 
The Association was merged into the Academy of Medicine. 

' "Women in Medicine" in Woman's Work in America, Mary Putnam 
Jacobi, M.D. 

* The New York Infirmary, 1857. 
The Woman's Hospital, Philadelphia, 1862. 
The New England Hospital, 1863. 
The Woman's Hospital, Chicago, 1865. 

3 The students of the college were admitted to certain dispensaries, but 
only the undergraduates. 

•< Infirmary Report, Jan. i, 1872. 



xvi Mary Putnam Jacobi 

ological Society, at a meeting, February 14, 1872.' cThe study 
of pharmacology occupied much of her time^' A lecture on one 
of these early studies was delivered to the students of the col- 
lege. ^ Lectures on " Medical Botany " were given at the college. ^ 
In 1873, Dr. Mary Putnam Jacobi and Dr. Anne A. Angel, 
a graduate of the Women's Medical College of the New York 
Infirmary, in 1871, obtained permission from the managers of 
the Mount Sinai Hospital to attend the children brought to the 
dispensary. This included all the children under twelve years 
of age, who applied to the dispensary for medical, surgical or 
orthopedic aid. Dr. Jacobi continued to attend until 1886. 
\^Thus she was responsible for the founding of the pediatric dis- 
pensary service at Mount Sinai Hospital, and from 1873 to the 
present time, a woman physician has been continuously in charge 
of this clinic. Prom 1871 to 1897, Dr. Jacobi served the In- 
firmary as visiting, attending and as consulting physician. 
From the opening of the hospital, in 1853, until 1886, sick chil- 
dren had been placed in the wards with adults, there being no 
other place for them. In 1886, Dr. Jacobi opened a little ward 
containing three beds. The Infirmary report for 1886 notes 
the fact "that one object for which the Infirmary had been in- 
corporated had been carried out in this year by the opening of 
a children's ward, completing the name. The Infirmary for 
Women and Children." In 1891, as a result of her work the 
ward_contained fourteen beds_.^^ 

From 1893 to 1902, Dr. Jacobi was a visiting physician to St. 
Marks Hospital. ^ 



' Anomalous malformation of the heart, Med. Record, 1872, vii. 

^ Lecture on atropin, Med. Record, 1873, viii. 

i Report Woman's Medical College of the New York Infirmary, 1872. 
Mary C. Putnam, M.D., Lectures on Medical Botany. 

•< The New York Infirmary for Women and Children, "Chartered in 1854 
as a dispensary, opened with an indoor department, in 1857. From 1857 
until 1865, the indoor department of the infirmary was limited to a single 
ward for poor lying-in women which contained but twelve beds, but in the 
dispensary several thousand patients a year were treated, and the young 
physicians living in the hospital also visited the sick poor in their homes. 
In 1S65, a new building was purchased for the hospital, which became enlarged 
to the capacity of thirty-five beds." Women in Medicine in America, by 
Mary Putnam Jacobi, M.D. 

5 Incorporated, 1890. 



Physician, Teacher, Author xvii 



Teacher 



Woman's Medical College of the New York Infirmary, 
1871-1889. 

Lectures on materia medica and medical botany, 1871-1872. 

Professor of Materia Medica, 1 872-1 873. 

Professor of Materia Medica and Therapeutics, 1873- 1889. 

New York Post-Graduate Medical School, Clinical Lectures 
on Diseases of Children, 1 882-1 885. 

"There is no power on earth which setteth up a throne or chair of state in 
the spirits and souls of men and in their cogitations, imaginations, opinions 
and beliefs, but knowledge and learning." — Bacon. 

"After the Blackwells, the most important factor in the 
movement that brought about the introduction of medical educa- 
tion for women and probably to be considered after them only in 
time, for her professional influence was co-ordinate with theirs, 
was Mary Putnam Jacobi^"] ^ "It was at the time of the greatest 
difficulty and disco-uragement for women students and practi- 
tioners" when Mary C. Putnam returned from Paris, in 1871. 
The standards for entering the medical profession were easy of 
attainment; women "without means or preliminary education 
could obtain a degree with almost nominal education. It seemed 
as though the low standard of qualifications then established 
would prove the most formidable barrier to the success of women 
in the profession," Mary C. Putnam "brought as her contribu- 
tion to the new work an enthusiastic love of the scientific side of 
medicine and a high standard of medical education."^ 

While still a student in Paris the faculty of the little college^ 
established by the Doctors Elizabeth and Emily Blackwell had 

' Walsh. History of Medicine in New York State, vol. i, p. 317. 

' Dr. Emily Blackwell, Mary Putnam Jacobi Memorial Meeting Address. 

3 "In New York, after much hesitation, a charter was obtained in 1865 
for the establishment of a medical college in connection with the Infirmary. 
This step was taken reluctantly because the desire of the Trustees of the 
Infirmary was not to found another medical school, but to secure the admis- 
sion of women to the classes for instruction already organized in connection 
with the medical charities of the city, and to one at least of the New York 
medical colleges. The demand of women for a medic^ education had resulted 
in the founding of small colleges in different places, all, with the exception of 
the Philadelphia school, limited to the narrow and cheap standard of legal 
requirements, and producing equally cheap and narrow results in the petty 
standard of medical education they were establishing among medical women 



xviii Mary Putnam Jacobi 

been waiting for the aid that the accomplished young doctor was 
to give them. Dr. Putnam had been asked by the Doctors 
Blackwell to join the faculty and teach materia medica in the 
new college. At the faculty meeting, May 6, 1870, the Secre- 
tary reported "that the return of Dr. Mary Putnam would 
be delayed by the closing of the University of Paris." The 
Franco-Prussian War had interrupted her studies. In October, 
187 1, Dr. Putnam began the lectures on materia medica and 
in the Spring Session on Medical botany. At the faculty meet- 
ing, April 26, 1872, "It was resolved that the faculty recommend 

students. The establishment of such a school called for money, but the money 
was forthcoming. A prospectus was issued announcing the requirements. 
In this prospectus a bold attempt was made to outline a scheme of education 
which should not only satisfy the conventional existing standard but improve 
upon this. It was realized, and, oddly enough, for the first time, that the 
best way to compensate the enormous disadvantages under which women 
physicians must enter upon their work was to prepare them for it with peculiar 
thoroughness. Women students were almost universally deficient in pre- 
liminary intellectual training; their lesser physical strength rendered a cram- 
ming system more often dangerous to health, and more ineffective as a means 
of preparation; and the prejudices to be encountered in their medical career 
would subject them not only to just but also to abundant unfair criticism. 
Instead therefore, of the senseless official system which then everywhere 
prevailed, it was proposed to establish a three years' graded course, with 
detailed laboratory work during the first years, and detailed clinical work 
during the last. A chair of hygiene was established for the first time in 
America, and an independent Board of Examiners was appointed consisting 
of professors from the diflferent city schools. By this means, the college 
voluntarily submitted itself to the external criticism of the highest local 
authorities. When the Infirmary put forth this prospectus, drawn up by 
the Doctors Blackwell, no college in the country required such a course. It 
was deemed Quixotic by many medical friends and several of its features were 
for a time postponed. The independent board of examiners, however, was 
established from the beginning, and, little by little, the other parts of the 
scheme were realized. In 1876, the three year's graded course, at first optional 
was made obligatory. At this time no college but Harvard had taken this 
step. The next year the class fell off one-third — a curious commentary on 
the character or circumstances of the students. In 1881, the college year was 
lengthened to eight months, thus abandoning the time-honored division of a 
winter and spring course, the latter comparable to the Catholic works of su- 
pererogation, and equally neglected. At the same time entrance examinations 
were established. These moderate improvements upon the naive barbarism 
of existing customs again reduced the classes one-half. When people first 
began to think of educating women in medicine, a general dread seemed to 
exist that, if any tests of capacity were applied, all women would be excluded. 



Physician, Teacher, Author xix 

to the Board of Trustees to invite Dr. Putnam to continue for 
another year as lecturer on materia medica with the honorary 
title of Professor." ' 

At the faculty meeting, September 27, 1872, Mary C. Putnam, 
M.D., is recorded as present. From that date until her resigna- 
tion in 1889, her active interest in the college and its students 
never flagged. It was her constant aim to make the work of her 
department more comprehensive, more thorough and more 
useful. She divided her subject into materia medica and thera- 
peutics. The former was taught during the first year and the 
latter during the two following years. The reasons for the 
change are eloquently and forcibly set forth in the introductory 
paragraph of the Lecture on Atropin. The college catalogue 
for 1873, notes the change. 

The interest of the young professor of materia medica and 
therapeutics was not limited to the problems of her own depart- 
ment. The question which concerned her, and which she studied 
from every point of view,[was the education of women as prac- 
titioners of medicine.' 



The profound skepticism felt about women's abilities was thus as much mani- 
fest in the action of the friends to their education as in that of its opponents. 
But by 1882, the friends dared to "call upon those who believe in the higher 
education of women, to help to set the highest possible standard for their 
medical education, and upon those who do not believe in such higher educa- 
tion to help in making such requirements as shall turn aside the incompetent — 
not by an exercise of arbitrary power, but by a demonstration of incapacity, 
which is the only logical manly reason for refusing to allow women to pursue 
an honorable calling in an honorable way. A career is open to women in the 
medical profession, a career in which they may earn a livelihood; a career in 
which they may do missionary work among the poor of our own country, and 
among their own sex in foreign lands; a career that is practical, that is useful, 
that is scientific. Even when a theoretic demand is not entirely realized in 
the actual facts of the case, its distinct enunciation remains a great achieve- 
ment; and, in an almost mysterious way, constantly tends to effect its own 
ultimate realization, and so it has been here." "Women in Medicine" by 
Mary Putnam Jacobi, M.D., in Woman's Work in America. 

The college closed in 1899. The opening of a medical department of 
Cornell University, admitting women, rendered a separate college for women 
unnecessary. 

■ Faculty minutes of the Woman's Medical College of the New York 
Infirmary, May 6, 1870; April 26, 1872. 

- Faculty minutes, March 7, 1873. 



XX Mary Putnam Jacobi 

In 1880, the faculty reported favorably upon the request of 
Dr. Jacobi to hold a weekly quiz for the entering students in 
anatomy and physiology. This weekly quiz became later "A 
Physiological Introduction to Therapeutics," given to the first 
year students Friday afternoons. Thirty-five years later, one 
of the students remembers vividly this quiz in the old college. 
"Its scope was not limited to anatomy, to physiology' nor to 
therapeutics, but embraced all related subjects as they were sug- 
gested by the question under discussion. Thus, the study of any 
organ meant a very comprehensive knowledge of its gross and 
microscopic structure, the source of its nerve and blood supply, 
its physiology, its correlation with its neighbors in the body. 
The study of any drug meant the accurate knowledge of its 
source and preparation and the botanical classification of the 
plant from which it was derived. Incidental questions of 
geography, history and literature were also discussed, and 
ranged through the subjects of medicine, ancient and modern 
history and the literature of the world. It was the most stimu- 
lating course in the first year, full of phenomenal new vistas to a 
young medical student." 

" At the first meeting of this class. Dr. Putnam Jacobi in- 
variably called the roll, looked at each student with a friendly 
open-hearted glance and asked, 'Where did you obtain your 
preliminary education?' The doctor knew each student by 
name after that first session, and on later occasions a stupid 

answer often brought out the retort, 'As a graduate of 

School, you should know better.' But no matter how stupid 
nor how uninformed she found her students, she was always 
patient, friendly and above all, stimulating. The sessions were 
rarely completed in less than two hours, and by that time there 
was always a long list of medical questions to be looked into. 
Incidentally, there were non-medical articles to be read. Never 
a Friday afternoon that did not stimulate much more than 
materia medica proper, never a Friday that was dry or dull. 
The will to learn was what she demanded of her students. She 
credited them with the mental ability and the industry to do the 
tasks required. She demanded much, but she gave in over- 
flowing measure, and never spared herself."' 

■ Martha Wollstein, 



Physician, Teacher, Author xxi 

V 

"To her students, Dr. Putnam taught the value of well directed effort 

for itself alone. No amount of time was too great, no labor too arduous to 
devote to their interest. She exacted in return care and thought and scientific 
accuracy. She would not tolerate superficial methods, while for honest intel- 
ligent effort, her appreciation was unbounded, and her encouragement, and 
help always ready. She stimulated others to do the best in their .power, and 
made them realize through her own ideals the greatness of the work which 
was before them." ' 

The entire problem of women in medicine, especially as 
practitioners of medicine was still debated. Dr. Jacobi realized 
fully that every student at the college, as a potential woman 
physician, must help to make a stronger link in the chain. 
Therefore she urged that "every student should be really educat- 
ed and not nominally." The College Catalogue of 1884, she 
wrote at the request of the faculty, and in it she called attention 
"to the work in the pharmacological, chemical and histological 
laboratories," an unusually advanced feature in a medical col- 
lege of this time. 

Dr. Jacobi always held the attention of her audience not only 
by the content of her lecture or address, but also by her delivery. 
Her manner was animated; she made no unnecessary gestures 
nor did she use oratorical methods. Her voice carried well, her 
face was expressive, illuminated; her eyes large, brown, often 
twinkling with himior. ^ 

A Thursday morning clinic in the diseases of children was 
given by Dr. Jacobi in the old college, primarily for the second 
and third year students ; others could and did attend. An acute 
gastric catarrh in its differential diagnosis carried the student 
through the whole domain of medicine. Every device either in 
making a diagnosis or in treating the patient was presented. 

The necessity for providing adequate medical opportunities 
for graduate physicians unable to attend the courses given in the 
universities of Europe had received much attention by the facul- 
ties of the medical schools in New York. In this medical problem 
Dr. Jacobi was greatly interested. The faculty of the Women's 
Medical College had considered the question, especially in its 
relation to women. Dr. Jacobi had been appointed in 1880,^ 
by the faculty to form a plan for post-graduate instruction in 
connection with the college and infirmary. The opening of the 

' Elizabeth M. Cushier's Mary Putnam Jacobi Memorial Meeting Address. 
' Martha Wollstein, M.D. 3 June 25, 1880, Faculty minutes. 



xxii Mary Putnam Jacobi 

New York Post-Graduate Medical School, admitting women 
equally with men, made unnecessary any further efforts in this 
direction by the Woman's Medical College. "In 1882, a school 
was opened for post-graduate instruction in New York, and Dr. 
Putnam Jacobi was invited to a place on its faculty, as the clinical 
lecturer on children's diseases, the first time a lectureship in a 
masculine school was ever, in this country, filled by a woman." ' 
The instruction was clinical, accompanied by charts, maps and 
microscopical and gross pathological specimens, illustrating the 
case exhibited. Dr. Jacobi's opening lecture on Diseases of 
Children was given in a room crowded with men, few women 
being present. The innovation of clinical teaching necessitated 
the procuring of patients for presentation. This required the 
education of dispensary patients. (The Post-Graduate School 
at that time had neither dispensary nor hospital.) Patients at- 
tending clinics controlled by colleges understood that they might be 
used for demonstration before the students. Dr. Jacobi's patients 
were sent from her large clinic at the Mount Sinai Hospital 
dispensary. These patients could not understand and frequently 
resented being sent to another clinic for this purpose. The most 
important cases were brought (at times forcibly) by the clinical 
assistant. Always instructive, the lectures were well attended. 

The Association for the Advancement of the Medical 
Education of Women 

Mary Putnam Jacobi, Founder, 1872 
President, i 874-1903 

Objects: To raise the standard of the medical education of women. 
"Article III. For this purpose it shall 
I. Create an adequate fund 

II. Apply this fund to the proper development of the course 
of instruction at the Woman's Medical College of the 
New York Infirmary." ' 

In 1878, "through the influence of the Association, the term 
of study (in the college) has been extended to three years and the 
sessions of each year increased to eight months, and preliminary 

■ "Women in Medicine" in Woman's Work in America. 
" Constitution of the Association for the Advancement of the Medical 
Education of Women, 1874. 



Physician, Teacher, Author xxiii 

examinations are required of students at entrance. The school 
is the only one in the country, with the exception of Harvard, 
where these conditions are exacted." "Two additional pro- 
fessorships have been supported, and a library founded." ^ 
"The assistance of the public is invoked to remedy an injustice 
which the public has tolerated — that of depriving human beings 
of the right to educate themselves. Every woman in America 
who has tried honestly to fit herself for the duties of a physician 
has been crippled by the organized, almost armed resistance 
opposed to her efforts to obtain an education." "The real cost 
of instruction, however, cannot be reduced except by diminishing 
its real value; for its main expense is that required for the brains 
of its teachers. At the present day the marked value of intellect 
is such that the highest instruction cannot be obtained except 
at an expense far beyond private resources. Intellectual values 
represent the accumulated wealth of many generations. It is 
impossible that any single generation should pay for them." ^ 
The report for 1883 deplores the fact that the association has not 
succeeded in securing a suitable building for the college. "A 
building is to a school what a body is to a soul. It may be more 
imposing than the mental work accomplished and then it is a 
disadvantage; but it may be so shabby as to depress the spirit 
of the work and so alienate support from it, and such is otir 
present case." ^ "Health is like the silent existence of those 
happy nations that have no history. But disease represents the 
commotion, the storm and stress, the drama and the convulsions 
into which the disturbed history of our race has usually been 
thrown." "We aim to exactly supervise the work of every 
student and to lead each into the knowledge and habit of daily 
intimate contact with nature, first in health, then in disease." 

In a report read at Lakewood, 1884,'' Dr. Jacobi speaks of 
some of the students as follows: 

"It may interest you to know a few details about some of our students. 
We have always had a certain number who were studying medicine for the 



' President's Report, 1878. 

'Our Future Aims, by Mary Putnam Jacobi, M.D. Address delivered 
at Union League Hall, March 26, 1878. 

3 Report of President, Mary Putnam Jacobi, M.D. 

4 The School of Medicine for Women of the New York Infirmary. Paper 
read at Lakewood, March 3, 1884. 



xxiv Mary Putnam Jacobi 



puppose of becoming missionaries in China and India. The fact that in these 
countries the women are not allowed to be treated by men physicians at all, 
offers an obvious field for women. One of our most intelligent graduates 
has been established for some years in China, has a large practice there, 
and is at the head of a large hospital. In this she is surgeon as well as 
physician, and has performed many important operations. This year we 
have a young Chinese girl as a student — the adopted daughter of an Ameri- 
can missionary, who has given her a most careful general education. She 
is extremely intelligent. The majority of our graduates of course settle 
down at home, scattered through country towns, rather than in large cities. 
Several have the largest practice of any of the half-a-dozen physicians in the 
place. . . . 

"While speaking of the students who have made, within otar circle at 
least, some little mark, I must not omit to mention one, who is at present 
most arduously engaged as physician to the out-practice of the Infirmary. 
This is composed of the sick who cannot come to the dispensary or be received 
in the hospital, but must be visited at their own homes. Our hard-working 
out-door physician receives no salary save her board and lodging; but the 
energy, fidelity, and conscientiousness with which she attends to her laborious 
duties could not be purchased for gold. Her district extends from 14th to 
Houston Street, and from 2d. Avenue to the East River. She often makes, 
on foot, twenty, or even thirty visits a day to houses scattered far apart 
through this large district ; and does not hesitate to go far down-town if a case 
presents itself that peculiarly appeals to her interest or sympathies. Where 
the salaried physicians attached to the city dispensaries would make, grudging- 
ly, one visit a day or less, this girl will not hesitate to retixrn two or three 
times in the twenty-four hour^, if she thinks that the case requires careful 
watching. She will pass hours in the garrets or cellars of wretched tenement- 
houses, absorbed in caring for the victims of frequently infectious diseases, 
and often rendering personal services that the attendants are too ignorant or 
clumsy to bestow. I shall never forget one case of a little child with diph- 
theritic croup, upon whom, one midnight last winter, I operated at her request. 
The child lived in a tenement in Canal Street, more than a mile from the 
Infirmary. But for ten days the young doctor visited it every two or three 
hours, and several times passed the entire night by its bedside. With every 
day that elapsed after the operation, the first faint hope of saving the child's 
life grew stronger, although in the vast majority of cases such children always 
die; but the prolongation of life was remarkable, and the young doctor's 
anxiety and enthusiasm grew constantly more intense. But finally she came 
to my house early one morning, and burst into tears. 

'"The child died last night,' she exclaimed. 'It was dreadful. I wish I 
were dead too ! ' 

"Perhaps you will call this feminine nerves! 

" I might continue to multiply instances of pluck, endurance, intelligence, 
and heroism from the annals of our institution. But I must not exhaust 
your patience. And I wish to return to the cardinal point of my subject: 
the reason, namely, why I bring it at all before you, who are not medical stu- 
dents, nor interested in medicine." 



Physician, Teacher, Author xxv 

In 1885, the name was changed to The Women's Medical 
Association, as the name hitherto used is somewhat inconven- 
ient.^ In May, 1899, the college closed. At a special meeting 
of the Women's Medical Association of New York City, of which 
Dr. Mary Putnam Jacobi was president, and at whose home the 
meeting was held, March 31, 1903, the disposition of the fund 
unexpended was proposed to be given to the Women's Medical 
Association. A committee was appointed to arrange the legal 
conditions necessary for the transference of the money which 
was accomplished at the annual meeting. May 20, 1903.^ 

Author 

" Not he is great who alters matter, but he who alters my state of mind. " — 
The American Scholar, Emerson. 

"Books are not absolutely dead things, but do contain a progeny of life 
in them to be as active as that soul was whose progeny they are ; nay, they do 
preserve as in a vial the purest efficacy and extraction of that living intellect 
that bred them." — Milton. 

The literary work of Dr. Mary Putnam Jacobi began in her 
ninth year as stories and essays, expressed in a childish vein, but 
nearly always in language with a trace of natural eloquence. 
Her education had been fragmentary. During her earlier years, 
instruction had been received chiefly from her mother, whose 
method was to make the little girl read aloud good literature, 
much reading of nothing but the best and a clear knowledge of 
the Bible being her substitute for modern training. 

Her first published story, entitled "Found and Lost," ap- 
peared in the Atlantic Monthly, April, i860, and for it she re- 
ceived eighty dollars. To "supplement her income" while 
studying in Paris, she wrote for her father's magazine, Putnam's 
Monthly, for the Atlantic Monthly and for Scribner's. One of 
these articles, "Some of the French Leaders: The Provisional 
Government of the Fourth of September," published in August, 

'Report for 1885. 

' Minutes of the Women's Medical Association, March 31, 1903; May 20, 
1903. The Women's Medical Association was organized when the college 
closed in 1899, and was composed of the members of the alumnae association 
of the Woman's Medical College of the New York Infirmary (organized in 
1870) and associate members. 

An address delivered before this association will be found on p. 494 • The 
first page has been lost. 



xxvi Mary Putnam Jacobi 

1 87 1, is described by Richard Watson Gilder as "one of the 
ablest ever printed in an American magazine." Thirty-six years 
later, Mr. Gilder declared, 

"I have just been looking again at that article; and bearing in mind all 
the essays that have appeared in all the magazines which have sprung up, 
stayed up, and passed down since, and not being sure, either, whether or not, 
all its conclusions will bear the test of time, I still am inclined to think this 
same essay is 'one of the ablest ever printed in an American magazine.'" ' 

Eight of these stories and sketches have been collected in a 
volume. Of these, four shov^^ the influence of her medical studies ; 
one, "A Model School," ^ written in 1870, describes what would 
be considered today (1924) a school in advance of this time in 
caring for the health and education of babies and children under 
fourteen years of age. The last essay was written during the 
siege of Paris, August, 1871.^ 

After her return from Paris, Dr. Putnam's literary work was 
devoted to medical subjects or to those relating to women in 
medicine, with the following exceptions: "Physiological Notes 
on Primary Education and the Study of Language"; "The Value 
of Life," a reply to Mr. Mallock's essay, "Is Life Worth Living," 
1879; "CommonSense Applied to Woman Suffrage," 1894. The 
first essay relating to women in medicine is entitled, "Shall 
Women Practice Medicine?" published in the North American 
Review, in Jan., 1882. "Women in Medicine," " the most able 
study yet written of the struggle and final triumph of women in 
entering the study and practice of medicine. The first para- 
graph reads: 

"The history of the movement for introducing women into the full practice 
of the medical profession is one of the most interesting of modern times. 
This movement has already achieved much, and far more than is often sup- 
posed, yet the interest lies even less in what has been so far achieved, than in 
the opposition which has been encountered: in the nature of the opposition; 
in the pretexts on which it has been sustained, and in the reasonings, more or 
less disingenuous, by which it has claimed its justification. The history, 
therefore, is a record not more of fact than of opinion. And the opinions 
expressed have often been so grave and solid in appearance, yet proved so 



' Mary Putnam Jacobi Memorial Meeting Address, by Richard Watson 
Gilder. 

' "Concerning Charlotte." 

3 Stories and Sketches, by Mary Putnam Jacobi, 1907. 

<" Women in Medicine," in Woman's Work in America, 1891. 



Physician, Teacher, Author xxvii 

frivolous and empty in view of the subsequent event, that their history is not 
unworthy of careful considerations among that of other solemn follies of man- 
kind." 

Dr. Putnam Jacobi's writings and work for women were 
mainly devoted to endeavoring to obtain for the qualified woman 
undergraduate admission to the best medical schools. Largely 
because of her efforts, Johns Hopkins Medical School opened its 
doors to women. A world war presented the opportunity to 
women for admission to any college of their choice, except 
Harvard, the first to be appealed to in 1847, and in 1924, still 
closed. In 1891, Dr. Jacobi wrote, "Unless all the opportunities, 
privileges, honors, and rewards of medical education and the 
medical profession are as accessible to women as to men, women 
physicians cannot fail to be regarded as a special and distinctly 
inferior class of practitioners." ' 

Her first medical writings were letters from Paris to the 
Medical Record, in 1867, entitled "Medical Matters in Paris," 
signed P. C. M., and were written to "supplement her income." 
Later ones include lectures, addresses, editorials and scientific 
papers, some read before societies, two written for the Cyclopcedia 
of Diseases of Children, two for Pepper's System of Medicine. 
She was specially interested in the problems of neurology. 
Hysteria, the subject of several of Dr. Jacobi's papers, has 
received renewed attention during and since the World War. 
Of this she wrote in 1 886 : 

"Notwithstanding the voluminous literature which exists on hysteria, 
something always remains to observe and describe in it. And this is to be 
expected when it is remembered that hysteria implies disarrangement of the 
functions of any part of the nervous system in its four spheres of intelligence, 
mobility, sensibility and visceral neurility. Every advance in our knowledge 
of these mysterious functions must, therefore, lead to some new point of 
view in regard to hysteria." ' 

In 1876, Dr. Jacobi wrote the answer to the question, "Do 

women require mental and bodily rest during menstruation, and 

^ to what extent?" For this she was awarded the Boylston Prize 

' of two hundred dollars from Harvard University for the year 

1876. 

' "Open Letters," The Century Magazine, February, 1891. 
* Essays on Hysteria and Brain Tumor, ajid some other cases of nervous 
disease, 1888. 



MEMBER OF MEDICAL SOCIETIES 

"Let us be wise, and not impede the soul. Let her work as she will. 
Let us have one creative energy, one incessant revelation. Let it take what 
form it will, and let us not bind it by the past to man or woman." 

— Margaret Fuller, 1844. 

New York County Medical Society 

Medical Library and Journal Association 

New York Pathological Society 

New York Neurological Society 

Therapeutical Society of New York 

New York Academy of Medicine 

Alumnae Association of the Woman's Medical College of 

Pennsylvania 
Women's Medical Association of New York City 

The story of the struggle of women to obtain official recogni- 
tion as physicians by admission to the medical societies, Dr. 
Jacobi relates in Women in Medicine. The first application by 
a woman was made in 1859 to the Philadelphia County Medical 
Society and was refused. The long struggle ended successfully 
in that state in 1888. In Massachusetts, in i860, Dr. Marie E. 
Zakrewska applied for admission to the State Society and was 
promptly refused. The struggle was long and bitter, ending in 
triumph for the women in 1879. In New York State, admission 
to the County Society met with no opposition. Dr. Emily 
Blackwell, the first woman, was admitted June 5, 1871; Dr. 
Mary C. Putnam, November 27, 1871. Dr. Abraham Jacobi 
tells the story in his Presidential Address of December, 1871. 

"Concerning our recent admission, I have another remark to offer. It 
is not a small satisfaction to me that, in this year of my presidency, one of 
the most urgent questions of the day should have been quietly and noiselessly 
answered. The admission of females into the ranks of the medical profession 
or rather — as their obtaining the degree of M.D. is a matter belonging to 



Member of Medical Societies xxix 

chartering legislatures and their obtaining a practice depends on the choice 
or prejudice of the public — into the existing medical societies, has been decided 
by you by a simple vote not attended either by the hisses and clamors of 
excited young men in medical schools or by the confusion and degradations 
of the meetings of a medical association. I think we can say that our action 
has finally settled a question, the importance of which was recognized by 
everybody. The vote of the largest society of the kind in the Empire State 
and I believe in the Union will have the effect of soothing the passions and 
leveling prejudices in the circles of the army of medical men, 40,000 strong 
in the United States, and of raising us in this respect to the standard of Euro- 
pean countries. Even the conservative seat of learning, Edinburgh, has 
admitted women to medical studies. Paris has turned out a woman doctor 
of medicine who will prove, I hope, none of the least ornaments of this society, 
the profession of this city, and our common country." 

"Entree into the New York Academy of Medicine in virtue 
of special medical work that I have already laid out," thus wrote 
the enthusiastic Paris student to her mother, January 13, 1870. 
The desire expressed in this letter was not attained until 1880, 
when she "was elected, though by the close majority of one to 
membership in the New York Academy of Medicine, the first 
woman to be admitted. . . . She was excluded from the Obstetri- 
cal Society by means of blackballs, although her paper as can- 
didate was accepted by the committee on membership and she 
received a majority vote." ^ The first medical society to which 
Dr. Jacobi was admitted was the Medical Library and Journal 
Association soon after her return from Paris. It was at a meeting 
of this society that she for the first time participated in a medical 
discussion. In 1873, she was admitted to the New York County 
Medical Society. She was the first woman sent as a delegate 
from the County Society to the New York State Society, in 1874. 
Her paper (page 284) was the first presented by a woman at a 
meeting of the New York State Medical Society. The New 
York Pathological Society admitted Dr. Jacobi in 1871, and at a 
meeting on February 14, 1872, she presented her first specimen. 
Dr. Wyeth, at one time president of the society, writes in 1914, 
of the meetings . 

"Dr. Mary Putnam Jacobi, whose knowledge of pathology was so thor- 
ough, whose range of the literature was so wide, and whose criticism was so 
keen, fearless and just, that in our discussions we felt it prudent to shun the 
field of speculation and to walk strictly in the path of demonstrated facts." » 

' Women in Medicine, Dr. Mary Putnam Jacobi. 
' With Sabre and Scalpel, John Allen Wyeth. 



XXX Mary Putnam Jacobi 

"She was a regular attendant at the Neurological Society." "She spoke of 
the papers read, always with interest, and always with point and brevity . . ." 
"It was a just recognition of her ambition, that she was finally made chair- 
man of the Section on Neurology of the New York Academy of Medicine." ' 

She also became a member of the Therapeutical Society. She 
was a member and president of the Alumnae Association of 
the Woman's Medical College of Pennsylvania. With the closing 
of the Woman's Medical College of the New York Infirmary, in 
1899, the Alumnae Association of the college, of which Dr. Jacobi 
was an honorary member, became the Women's Medical Asso- 
ciation of New York. This association she helped to organize 
and served as president. 

Dr. Mary Putnam Jacobi died on June 6, 1906. At the age 
of ten, she wrote to her grandmother : 

"Vague longings beset me. I imagine great things and glorious deeds; 
but Ah! the vision passes like a fleeting dream and the muddy reality is left 
behind. I would be great. I would do deeds, so that after I had passed into 
that world, that region beyond the grave, I should be spoken of with affection, 
so that I should live again in the hearts of those I have left behind me." 

Looking back upon her life and the things that she accom- 
plished, we can only say that she did become great, that she did 
deeds for which she is spoken of with affection, and that she lives 
again, and forever, in the hearts of those who knew her. 

She has joined "the choir invisible 
Of those immortal dead who live again 
In minds made better by their presence: 
In thoughts sublime that pierce 

The night like stars 
And with their mild persistence urge 
man's search 

To vaster issues." 



' Mary Putnam Jacobi Memorial Meeting Address, by Dr. Charles L. 
Dana. 



MARY PUTNAM JACOBI 

Dr. Mary Putnam Jacobi began her medical writings in 
letters from Paris to The Medical Record. They ran from 1867 
when she was 25 years old to 1871, when she graduated. They 
gave a very accurate picture of the medical and surgical activi- 
ties of this time, with occasional personal touches that enlivened 
her very conscientious descriptive work. These letters still 
possess interest and have a definite historical value. 

When she had established herself in practice in New York 
she began at once to publish medical articles and she continued 
to do this yearly in the form of reports, pathological records, 
addresses and reviews until in 1900 when her final illness over- 
took her. 

At the beginning the subjects of pathology and pathological 
anatomy especially, interested her. She probably realized that 
a young doctor with little clinical experience was best fitted to 
contribute concrete things like pathological specimens about 
which there would be little question of opinion. She, however, 
early showed an interest in therapeutics; and this interest was 
emphasized by her appointment as Professor of Materia Medica 
and Therapeutics in the Woman's Medical College. 

I find in her writings about 50 contributions to pathology; 
20 to neurology, about the same number to pediatrics, a dozen 
contributions to physiology and an equal number to education. 

Dr. Jacobi's contributions to medicine were always made with 
great care. They showed familiarity with previous work and a 
keen desire to add something definite to human knowledge 
through her own observations. She quite often brought her 
special knowledge of social life and of educational problems into 
her medical investigations. Running through her writings 
appears her ambition to secure equal rights for women in medi- 
cine and in the state, and it is due not a little to her that eventual • 
ly such rights have been secured. 



xxxii Mary Putnam Jacobi 

Dr. Jacobi added many clinical and pathological and educa- 
tional facts which still remain valuable to her chosen science. 
She will be remembered by these and also by the example of her 
courageous and path-breaking career and by her success in pro- 
moting the elevation of woman's status as contributors to science 
and as efficient members of a learned profession. 

—Charles Loomis Daxa, M.D. 



MARY PUTNAM JACOBI 

LETTERS TO THE MEDICAL RECORD, 1867— 1870— 
MEDICAL MATTERS IN PARIS. SIGNED P.C.M. 

To the Editor of the Medical Record. 

Sir — In Paris, the absence of the excitement afforded by 
political elections is amply compensated, for a limited circle of 
people at least, by the continually recurring elections at the 
Academy, and nominations at the concours. You are aware 
that all the hospitals in Paris are under the control of a central 
administration, who appoint all the physicians. The appoint- 
ment is made by the decision of a jury, drawn by lot, from among 
the actual hospital physicians, who decide the merits of the 
various candidates for a vacancy, after submitting them to 
severe clinical examinations. A concours of this kind has just 
terminated, in a manner infinitely disappointing to fifty of the 
candidates who were rejected, and highly agreeable to the two 
who were deemed worthy for the important position. The 
successful candidates were MM. Olliver and Praust. 

A new contest is now going on at the Academy, which is 
busy in deciding upon nominations to the chairs of surgery and 
medicine, left vacant by the death of Jobert and Rostan. Among 
the foremost candidates for the first position is M. Langier, who 
has recently added to his previous claims to distinction by an 
exceedingly interesting memoir upon cerebral concussion. The 
phenomena occasioned by this accident are analyzed with the 
greatest care, and referred to that part of the encephalon which, 
according to present physiological ideas, presides over the func- 
tions compromised. The cerebral hemispheres are certainly 
affected, for the intelligence, all voluntary and affective faculties, 



2 Mary Putnam Jacobi 

and the consciousness of all sorts of nervous irritation, are en- 
tirely suspended. Unconscious sensibility, on the contrary, and 
all movements resulting from reflex action, are, however, pre- 
served, which proves that the pons arolii, and probably the 
corpora striata and thalami optici are in all their integrity. M. 
Langier discusses the question, why the hemispheres alone should 
suffer from a shock that must be transmitted to them through 
portions of the encephalon that remain uninjured. He accounts 
for this immunity on the part of the pons, the bulb, etc., by the 
fact of their superior firmness of structure, and the more secure 
position of their gray masses, which, being in the centre of the 
white tissue, are much less exposed to shock than the gray sub- 
stance of the hemispheres distributed over their surface. 

It is not certain whether this memoir will elect M. Langier, 
but it is discussed in his favor. Another illustration of the value 
of disease in dissecting apart the involved functions of the brain, 
is furnished us this week by a most interesting case at the Hopital 
St. Antoine, in the service of M. Jaccaud. It was a case of 
aphasia, the disease that has been rendered so famous by M. 
Broca's theory, which attaches it to a lesion of the third anterior 
convolution of the left cerebral hemisphere. The accident is 
not uncommon, but the opportunity for verifying the diagnosis 
by an autopsy is comparatively rare, as the disease is rarely or 
never directly fatal. Hence this case, which afforded such an 
opportunity, is one specially valuable. 

The patient in question was already a victim to Bright's 
disease of the kidney, for which he had been in the hospital since 
last June. At the period of the accident he suffered from an 
extensive oedema, without ascites; albumen was abundant in the 
urine; he presented, moreover, a systolic souffle at the point of 
the heart. On the 226. of January, without any premonitory 
symptoms, this patient suddenly discovered that he had lost the 
power of speech, and on the morning visit, the next day, he was 
found in a state of great disquiet, pointing to his lips and tongue, 
indicating by signs that he wished to speak but could not. There 
was not the slightest lesion of any of the limbs, and at the face 
only a slight paralysis of the zygomatic and elevator muscles of 
the right side of the mouth, which was drawn a little to the left. 

The understanding was not in the least impaired ; he took up 
any article that was named to him, but could not name them 



Letters to the Medical Record 3 

himself. When a person pronounced before him a word distinctly 
articulated, he examined carefully the motion of the lips, and 
succeeded in uttering some monosyllable, as "bien," "vous," 
but that was all. He was equally unable to write as to speak, 
never getting beyond the first letters of his name. 

In presence of these symptoms, and on account of the mitral 
insufficiency, M. Jaccaud pronounced a diagnosis of lesion of the 
third frontal convolution, probably at the left (since that is the 
case seven times out of ten), and probably in consequence of an 
embolus. 

The aphasia began to disappear by the end of the 30th, and 
by the end of February was entirely gone. The patient died on 
the 22d of April, and at the autopsy the diagnosis was fully 
confirmed by the discovery of — first, complete fatty degenera- 
tion of the kidneys; second, vegetations on the mitral valve, and 
insufficiency; third, buried in the white substance of the third 
frontal convolution of the left hemisphere were two haemorrhagic 
cysts, which contained some drops of liquid. One of these cysts 
was the size of a pea, and situated at the right of second, whose 
volume was three times as considerable. The surface of the 
section was distinct and well limited; not only the lesion did not 
extend beyond the convolution in question, but the gray matter 
of that was untouched, and from the exterior appeared perfectly 
healthy. The other parts of the encephalon, as also the mem- 
branes and the arteries, were examined with great care, and 
found perfectly sound. 

Hence this case brings fresh support to the theory that places 
the power, not merely of speech, but also expression by writing, 
in this limited part of the brain. 

Among the candidates for the vacant place in medicine at 
the Academy, M. Hdrard is one of the most prominent. His 
claims to the honor chiefly rest upon a work that he has published 
this year upon pulmonary consumption. The initial idea of this 
striking book was originally promulgated in Germany by Rein- 
hardt, but M. Herard and his colleague, Cornil, have done much, 
not merely to popularize Reinhardt's views, but to bring to their 
support abundant clinical demonstration. You are aware that 
Reinhardt completely upsets the old descriptions given by 
Laennec and Louis of the cheesy tubercle. According to recent 
microscopical researches, the yellow masses thus denominated 



4 Mary Putnam Jacobi 

are formed, not by the ulterior development of a heterologous 
deposit, but of a pneumonia, excited by the presence of the crude 
tubercles in the connective tissue of the lung. This pneumonia 
differs from ordinary acute pneimionia, rather in its anatomic 
and microscopic characters, than in its constitutional effects. 
Instead of an exudation of fibrine into the alveoles, there is an 
exudation of pavement epithelium and leucocytes. In other 
words, it is a catarrhal pneumonia, similar with that caused by 
artificial experiment. To this pneumonia Herard and Cornil 
refer all the general symptoms of phthisis, the fever, emaciation, 
and destruction of the vital forces. They maintain that the 
presence of the crude tubercle in the lung excites no general dis- 
order, and it may remain latent for an indefinite period, until, 
generally in consequence of some special accident, the tissue 
surrounding it inflames. This inflammation may subside spon- 
taneously or under the influence of treatment, but relighted 
again and again, it finishes by entering upon the cheesy state 
(pneumone caseuse). At this stage the contents of the alveoles 
liquify, the hepatised lung softens, and the cavern is formed 
which for so long has been exclusively attributed to the softening 
of the tubercles. These also soften, but their size always re- 
mains the same as that of the original gray granulation. Even 
when softened they may be distinguished from the masses of pneu- 
monic lung through which they are disseminated, by the presence 
of small nuclei and the cellules, called by Robin cytoplastians. 

In consequence of this view of the anatomy of phthisis 
(which approaches in its nature somewhat to that proclaimed 
by Broussais), M. Herard lays special stress upon local revulsives 
in the treatment, iodic frictions, blisters, and the actual cautery. 
The tonic and stimulant general treatment is of course also 
maintained, though our American use of alcohol is rejected. To 
a certain extent, a moderate use of tartar emetic, as recommended 
by Foussagrines, is counselled. 

This treatment does not procure brilliant results in the 
hospitals, where the patients generally are too far advanced to 
be saved, but M. Herard declares that a fair share of success 
may be obtained in private practice, where the disease is treated 
at the very beginning. 

M. Marriothe communicates to the Bulletin de ThSrapeutigue, 
an account of some clinical experiments made by himself this 



Letters to the Medical Record 5 

winter with muriate of ammonia, in the treatment of catarrhal 
fevers that have been epidemic in Paris. These fevers assumed 
a remittent or intermittent type, without losing their distinc- 
tively catarrhal character, but proved quite obstinate to sulphate 
of quinine. In accordance with a suggestion by Schmidtmann, 
who was in the habit of giving muriate of ammonia in the declin- 
ing period of gastric fevers when they assumed a periodical form, 
M. Marriothe tried the experiment, at first in some cases com- 
plicated with very severe neuralgies, which interrupted sleep, and 
even extorted cries from the patient. The effect of the muriate 
was surprising. In mild cases the febrile attacks and the neural- 
gies ceased upon the first or second day ; in more severe forms the 
success was not complete till the third or fourth, but there was 
always amelioration by the first or second. 

M. Marriothe thinks that the salt has an important influence 
in moderating the erethism of the mucous membranes, but that, 
besides, it acts directly on the nervous system, without the occur- 
rence of any intermediate phenomena, as vomiting, sweating, 
diarrhoea, etc. The dose found necessary to arrest the febrile 
attacks and cahn the neuralgia, varied from thirty to sixty grains 
in the course of the day, being administered in portions of 7-15 5 
every three or four hours. 

An operation that Dr. Brown has done much to bring into 
favorable notice in England, is beginning again to excite the 
attention of French physicians. I mean the capital operation of 
ovariotomy, upon which M. Boinet has just read an elaborate 
report before the Academy. The report begins with reference to 
an American, the first who practised ovariotomy with the definite 
intention of extirpating the diseased organs. Dr. Ephraim Mac- 
Dowell, of Kentucky. This surgeon, between 1809 and 1830, 
operated thirteen times, and obtained eight cures. Baker Brown 
reports twenty-nine successful cases out of thirty-two operations. 
Even were the success in much smaller proportion than this (and 
the recent expose of Brown's character renders us cautious about 
accepting his statistics), the operation would be legitimate in a 
disease that conducts its victims almost inevitably to the grave, 
the deaths being 95 in 100. M. Boinet reprobates the timidity 
of the French surgeons, who have so long recoiled before this 
operation, and proceeds to give many useful hints upon the pre- 
cautions necessary to insure success. 



6 Mary Putnam JacobI 

In the first place, the operation should never be performed 
at a hospital, where peritonitis invariably follows the opening of 
the abdomen; a healthy, isolated locality should be selected, and 
a room prepared whose temperature should be maintained at 20 
to 25 degrees centigrade. Secondly, the nature of the cyst must 
be carefully considered. If it be simple, unilocular, containing a 
liquid, clear, limpid, and serous, or even purulent or sanguinolent, 
the operation is inappropriate. Nelaton's system of iodine injec- 
tions should be first tried. But if the liquid, though at first 
serous becomes unctuous and fatty, ovariotomy is the only 
resource. Other proofs that the cyst is multilocular, or that it 
contains pathological productions contra-indicating the use of 
iodine, signs of the increase of the tumor, and exhaustion of the 
patient, are circumstances that should also call for the operation. 
Among the contra-indications should be reckoned the existence 
of grave complications, an early stage of the disease, pregnancy, 
or tumors in the uterine walls. 

The operator should place himself at the right or left side of 
the patient, instead of between the knees, as recommended by 
some surgeons. The incision should be made on the median line, 
and of sufficient size to admit the free introduction of the hand 
in the cavity, for the purpose of recognizing the size and position 
of the tumor and the extent of the adhesions, which exist three 
times out of four. When these adhesions are slight and can be 
easily torn, they occasion no inconvenience; but if large and 
resistant, their action frequently causes dangerous haemorrhage. 
The dangers of too short an incision have been frequently ex- 
posed; the adhesions are not distinctly perceived, the cyst is 
imperfectly grasped, the other ovary cannot be seen, the pedicle 
is tied with difficulty, and sanguineous effusions may take place 
in the abdominal cavity without the knowledge of the surgeon. 
Should the first incision prove too short to avoid these incon- 
veniences, a second can always be practised with safety. 

The incisions should divide the different layers of the abdom- 
inal wall in succession, to avoid too sudden entrance into the cyst. 
As soon as this is discovered, the hand should be introduced, to 
ascertain the existence of adhesions or neighboring tumors. In 
the second case, it is only necessary to enlarge the incision ; in the 
first, the adhesions must be detached by the hand, or destroyed 
by the scissors or hot iron. They should not be torn. 



Letters to the Medical Record 7 

Before tapping the cyst two assistants should press upon the 
abdominal walls, in order to force the cyst to project between 
the lips of the incision. The puncture is then made with a trocar, 
and by means of the foregoing precaution the liquid is prevented 
from running into the peritoneal cavity. If there is more than 
one pouch, the first should be held by pincers, or tied, while the 
others are drawn out of the cavity. If the cyst, on its retreat, 
draws a portion of its adherent intestine, it is important that this 
be detached ; if that be impossible, a piece of the cyst must be cut 
out, and left attached to the intestine. Care must be taken, how- 
ever, to remove the internal secreting membrane from this fragment. 

All bleeding vessels, whose volume is not too considerable, 
should be twisted, or cauterized with a hot iron or the perchloride. 
Only when this method is impossible should the vessels be tied. 

The wound should not be closed until the last drop of liquid 
has ceased to flow. An eminently useful precaution consists in 
placing in the inferior angle of the wound, or in the recto- vaginal 
cul-de-sac, a caoutchouc tube, by which any liquid subsequently 
effused may drain off. MM. Keith and Koeherle attribute a 
great number of their successes to the observance of this pre- 
caution. Boinet has no dread of the introduction of air into the 
peritoneum, attributing all inflammation to the action of liquids, 
and not air. 

A double line of sutures is necessary, one deep, the other 
superficial. M. Boinet decides in favor of including the peri- 
toneum in the suture, to avoid the danger of this membrane 
contracting adhesions with the intestine. The pedicle should be 
compressed by a toothed clamp, which has the advantage of 
compressing the tissues and preventing heemorrhages. If the 
pedicle is voluminous, it should, however, be tied, or the liga- 
ture combined with the clamp. When the size of the pedicle, or 
its insertion on the uterus, presents unusual difficulties, a thread 
of ligature should be passed around it before the cyst is cut away. 

M. Boinet concludes, 

" that the ovariotomy should be accepted with as much enthusiasm as all other 
capital operations ; and that now that the bases of diagnosis are better assured, 
and the operative procedures more perfect, the subsequent treatment better 
understood, more advantageous results will doubtless be obtained." 

M. Demarquay, surgeon of a Maison de Sante, presents a 
report on the topical application of iodoform in the treatment of 



8 Mary Putnam Jacobi 

cancer of the uterus. This agent employed in the crystalline 
form, in a dose of 7 to 15 grains, is mixed with a sufficient quan- 
tity of butter of cocoa, and the suppository thus formed, intro- 
duced into the vagina, or an ulceration of the carcinoma, if that 
exists, — a tampon of cotton is placed in front. The general 
effects are slightly observable, although the iodine from the 
drug (C^HP) is absorbed and may be discovered in the saliva 
and urine. But the local suffering is almost infallibly soothed; 
the swelling of the abdomen diminishes; and the ease procured 
lasts as long as the medicament is continued, is broken up by 
the interruption of its administration, and reestablished when 
that is renewed. 

Dr. Morel, the distinguished alienist, writes an interesting 
article in the Archives of Medicine for May, upon progression in 
hereditary insanity and nervous diseases. Not content with the 
vulgar fact of hereditary influence in the transmission of such 
disorders, he, in company with an army of modern confreres, 
seeks the laws that govern this hereditary transmission. I have 
not space left to enter into all the details of his curious paper, 
I can only mention three or four of the most striking conclusions, 
drawn from a great number of facts; ist. Insanity, epilepsy, 
hysteria, chorea, eccentricities, dypsomania, etc., are only the 
branches of an identical constitutional vice of the nervous sys- 
tem, and may be transformed, the one into the other, by way of 
hereditary transmission. 2d. Such transformation is more fre- 
quent than the transmission of the same form of disorder. When 
a simple eccentricity of a parent becomes insanity in a child, &c., 
the hereditary taint is said to be progressive ascendant, and the 
opposite case progressive descendant. 3d. Whenever the sev- 
eral children of parents presenting a nervous taint, are markedly 
dissimilar in appearance and character, the taint will almost 
surely be transmitted, and progressive ascendant. It seems in 
this case as if the whole force of family likeness was concentrated 
in the depths of the nervous system. 4th. In such families it is 
common to observe that one or more of the members are gifted 
with remarkable intellectual ability, while others are idiots. 

The third proposition especially constitutes the theme of 
M. Morel's present paper. The fourth identifies his views with 
those of Dr. Moreau, who, in his remarkable work on morbid 
psychology, unhesitatingly ranks genius among the neuroses, 



Letters to the Medical Record g 

and assigns to it an origin identical with that of epilepsy, in- 
sanity, and idiocy. 

Paris, Tune 1 8, 1867. 

P. C. M. 



To the Editor of the Medical Record. 

Sir — At the last seance of the Academy of Medicine the 
discussion on tracheotomy was continued, and M. Peter made 
quite a discourse on the subject, describing the practical dif- 
ficulties in the way of the operation, and suggesting means of 
overcoming them. Among the principal, is the small size of 
the trachea in young children. The operator is liable, in making 
an incision with the bistoury directed perpendictdarly to the 
windpipe, to pass completely through that organ to the oesopha- 
gus. Again, the index-finger used to hold the trachea in place, 
frequently pushes it to one side, so that the incision is made to the 
right or left of the median line. This would be of small conse- 
quence if the trachea was steadily maintained in the first position, 
but too often the finger slips, the trachea returns to the middle 
of the throat, and the incision is concealed from view. These 
difficulties are more formidable as the child is younger, but M. 
Peter thinks that the age alone never offers a formal contra- 
indication, since it is well in case of need to operate on the smallest 
child, and give it a chance for life at a moment that all others are 
lost. 

M. Peter considers, however, that tracheotomy is never 
necessary, and therefore never advisable, except in cases of 
pseudo-membranous croup, and believing that pseudo-mem- 
branous angina invariably accompanies this disease, he abstains 
from the operation whenever he cannot find false membranes 
in the pharynx. The extension of the membranes to the bron- 
chial tubes is, however, of course a circumstance of unfavorable 
omen for the operation. It is often difficult to diagnose this 
complication. M. Moutard Martin signalizes 'pale asphyxia as 
an excellent sign. M. Peter adds, an unusual frequence of the 
respiratory movements, whose rapidity is slackened in simple 
laryngeal croup. Whenever there are more than fifty inspira- 
tions a minute, there is good reason to suspect a pseudo-mem- 
branous bronchitis. 



10 Mary Putnam Jacobi 

Subsequent to the operation, the practitioner possesses 
another sign of this formidable complication. When the canula 
left in the tracheal wound does not become filled with mucosities, 
when at the end of twelve hours it is still dry, there is too good 
reason to believe that the mucous surface of the bronchial tubes 
is covered with false membranes which effectually prevent 
secretion. 

M. Peter declares that pseudo-membranous bronchitis is quite 
frequent, occurring, in his experience, 52 times in 105 fatal cases. 

Pneumonia coincident with the croup does not absolutely 
forbid the operation. M. Grisolle observes, that his first success- 
ful case of tracheotomy was embarrassed by this complication. 
M. Nelaton had been called upon to operate, but recognizing the 
concomitant pulmonary lesion, refused. M. Grisolle then as- 
sumed all the responsibility, and operated himself — ^the child 
recovered. 

M. Archambaud had obtained 21 cures among 67 operations, 
including two upon adults. The most of these cases had already 
reached the last period when the operation was performed, the 
patients sometimes being completely insensible. Among 53 
operations made under such circumstances, 17 had succeeded, and 
among 12 cases treated at an earlier stage of the disease, 4 were 
saved. The proportion therefore is about the same. 

M. Peter assumes as contra-indications, an excessive waxy 
pallor, ganglionic engtjrgement, extreme puffiness of the neck, 
which is neither oedema or emphysema, all signs of general in- 
toxication. 

Cases of stridulous laryngitis are successfully treated by M. 
Peter with steam. The child is surrounded by half-a-dozen 
basins filled with boiling water, so that the respiratory organs 
may be incessantly bathed in the humid atmosphere ; the croupal 
symptoms generally subside in about an hour. 

The month of June has been unfavorable for the performance 
of tracheotomy, since out of eight operations, divided equally 
between the Children's Hospital and Hopital St. Eugenie, six 
have proved fatal. 

Appreciation of Medical Constitutions. 

This observation enters into a report, presented by Mr. 
Besnier to the Academy of Medicine, on the medical constitution 



Letters to the Medical Record n 

for June. An effort is being made just now to collect materials 
for a rigorous appreciation of "medical constitutions." The 
value of such an appreciation cannot be too highly estimated, 
when it is remembered how largely this condition enters as an 
element into the effect of medical treatment. There can be no 
question, that the reputation of a large number of methods and 
medicines has been made by the fact that they were administered 
at a moment when the disease had assumed a benign type, and 
tended of its own accord to a favorable issue. During this 
month of June, nearly all the cases of typhoid fever in the hos- 
pitals have recovered. There has not been less, but rather more 
of the disease than usual, and the first stages have frequently 
opened with considerable severity, but any dangerous symptoms 
have quickly abated, and the course of the malady has been 
equally satisfactory under any treatment. This reminds me of 
an amusing anecdote related by Dr. Maximin Legrand m the 
feuilleton of the Union Medicate: 

One day, the gargon de service, employed in the wards of M. Fouquier, 
appeared with two black eyes, and his face covered with bruises. "What is 
the matter with you, my man? "inquired M. Fouquier, always kind and polite. 
"I have been fighting with M. Bouillaud's infirmier, and he is better done for 
than I am." "You were very wrong; what were you fighting about? " "Be- 
cause he insisted that it is always necessary to bleed in typhoid fever!" The 
gravity of the physician was not proof against this unexpected reply. 

When it is remembered that M. Bomllaud is the author of the 
famous system of bleeding in pneumonia twice a day, coup sur 
coup, and extends his sanguinary propensities to typhoid fever 
also, the belligerent enthusiasm of his humble subordinate may 
be easily explained. 

The Administration of Mercury in S3rphilis. 

At the Imperial Society of Surgeons, the discussions still 
turn upon the question of the administration of mercury in 
syphilis, a question that seems subject to periodical agitation. 
The most conspicuous part of the debate has been that sustained 
by M. Despr^s whose views have been entirely special, "so 
special," observes Dr. Reveillant, "that he remained entirely 
alone in his opinion." For M. Despres is radical enough to deny 
any efficacy to mercury whatever, in the disease in which it has 
for so long been considered the sheet-anchor. He is resolved 



12 Mary Putnam Jacobi 

never to administer the baneful drug either in primary, or secon- 
dary, or tertiary syphilis. Theoretically, he bases his prin- 
ciples upon the idea, that the malady is already so exhausting to 
the patient, that the debilitating effects of mercury can work him 
nothing but injury. Practically M. Despr^s appeals to the 
result of his experience in the Hopital Leourcine, among 234 
patients, of whom some were subjected to the classical treatment, 
others to a course of tonics. Among the first, a percentage of 
28 for 100 returned after more or less time to the hospital for 
fresh treatment of the disease, while in the second class the 
returns were only 10 for a hundred. M. Despr^s declares, rather 
fancifully, that the physician should endeavor to restore his 
patient to a "life of infancy," regulating his food, sleep, and 
exercise, building up his shattered constitution, and that nature 
would eliminate the poison. 

"We cannot believe that a purely empirical medicine can be a contra- 
poison against syphilis, or that there is any sense in employing a drug that 
exists in the blood like foreign matter, which does not assimilate with a single 
fluid, and which, even in exercising a certain perturbating and deleterious 
effect on the economy, neither solicits nor suspends the regular exercise of a 
single function." 

The only points of importance in M. Despres' remarks, are 
the statistics, and their value is vigorously contested by M. 
Depaul. He observes that the comparison between the two 
modes of treatment was not sufficiently extended, and moreover, 
that the basis of comparison was fallacious, since a number of 
the patients who had been treated by expectation, probably 
absented themselves from the clinique, not because they were 
cured, but because they were disgusted with the treatment. 
Nothing exasperates a hospital patient so much as the suspicion 
that nothing is being done for him. He maintained that this 
expectant system was extremely dangerous, since the most 
serious destruction of tissue, such as the perforation of the pala- 
tine vault, might take place while the physician was watching 
with folded hands. M, Depaul laid especial stress on the efficacy 
of mercury administered for syphilis contracted during pregnan- 
cy, when, he declares, it uniformly prevents abortion, in recent 
cases. 

A case that recently occurred in the service of M. H^rard at 
Laribaissiere, which I had an opportunity of observing myself, 



Letters to the Medical Record 13 

is in entire accordance with this assertion. The subject was a 
woman of about 35, in the third month of pregnancy. Several 
years previous she had been treated at Lourcine for primary 
syphilis, and two years ago had been an inmate of Laribaissi^re 
for syphilitic angina. Each time she had completely recovered, 
and it was impossible to ascertain whether the renewal of the 
disease was a manifestation of the original malady, or the result 
of a new infection. At the moment of her entrance, in June, the 
patient presented an eruption of syphilitic erythema, copper- 
colored blotches disseminated over the entire body; a small 
tumor on the right frontal bosse, with broad base, but slight ele- 
vation, but the seat of lancinating pains exasperated at night, 
and which extended also to the temples and the ears: a gray 
ulcerated fissure at the left commissure of the lips; a grayish 
plaque mugiieux on the right labium majus of the vulva. Fine 
subcrepitant rales could be heard at the summit of the left lung. 
A cough had existed for several months, but the patient professed 
to have been perfectly free from syphilitic accidents at the com- 
mencement of her pregnancy. She was ordered a pill of corro- 
sive sublimate containing five centigrammes, to be taken every 
evening. This was the nth of June. On the 12th, in addition 
she commenced to take 25 centigrammes of iodide of potassium 
every morning. By the 19th the pains in the head had entirely 
ceased, and the eruption had begun to fade. By July nth the 
tumor had almost disappeared, as also the plague muqueux, and 
the eruption was entirely gone. The fissure of the lips was also 
healed, and the patient left the hospital on the i6th of July in a 
perfectly satisfactory condition (the cough also was diminished), 
both as regards her general health and the march of the preg- 
nancy. The treatment was continued uninterruptedly during 
the first month ; after that, the sublimate was suppressed, and the 
iodide alone continued. 

MM. Guerin, Perrin, Verneuil, and Velpeau, also took up 
arms in defence of mercury. They nearly all insisted upon a 
prolonged treatment, not less than two years, as absolutely 
necessary to radical cures. M. Guerin therefore disapproves of 
large doses. He prefers the protiodide associated with opium, 
but in case that is supported with difficulty, he has recourse to 
fumigations with cinnabar. He does not believe that inunctions 
alone are sufficient, while they have the inconvenience of pro- 



14 Mary Putnam Jacobi 

ducing salivation more speedily than other methods of adminis- 
tration. M. Perrin, with an experience of 470 cases, treated at 
Val de Grace, disbelieves that mercury administered in primary 
syphilis can prevent the regular evolution of the disease, and 
therefore confines himself to local cauterizations, and only 
commences general treatment with the appearance of secondary 
symptoms. He is careful to administer chlorate of potassa coin- 
cidently with the mercury in any form. He acknowledges that 
no treatment is infallible against relapses, but that the physician 
is simply called upon to be perseverins^, and reapply the treat- 
ment at each outbreak until he has mastered the disease. 

M. Verneuil and Velpeau believe in the beneficial effects of 
mercury at all periods of the disease, and the former declares 
that salivation is an imaginary- phantom. Syphilis may exhaust 
itself spontaneously, but such cases are rare, and generally the 
patients are exhausted first. 

The only person who in any way sustained the views of 
Despres was M. St. Germain, who, while professing to believe 
that mercury does render some indefinite service in syphilis, 
declares at the same time that he considers it as useless against 
chancre, that he has a "certain tendency not to administer it in 
secondary syphilis," and that he always combats tertiary symp- 
toms by iodide of potassium. 

It appears, therefore, that not much new light has yet been 
thrown on this important subject by the debate. The society 
is waiting to hear the opinion of M. Diday, pupil of Ricord, 
whose voice would naturally have much influence. 

More original views were presented in a recent discussion at 
Lyons, on the same subject, /where several of the members main- 
tained that it was unnecessary to spend much time or thought 
upon the cure of patients who had fallen a prey to the disease in 
consequence of misconduct, and that especially such patients 
should never receive the benefit of gratuitous treatment. 

Vesico-Vaginal Fistula Treated by the American Method. 

M. Courty, Professor at Montpellier, publishes an account 
of six cases of vesico-vaginal fistula, successfully operated by the 
"American method." The Bulletin of Therapeutics publishes 
the details of two that presented unusual difficulties. In one, 
the fistula, five centimetres long, dated from four years, the 



Letters to the Medical Record 15 

urethra was obliterated, and vagino-pubic adhesions existed. 
There was also a hernia of the bladder. Owing to the adhesions, 
the operation was exceedingly difficult, the haemorrhage abun- 
dant, and the lips of the wound did not completely close. After 
a second operation, however, performed upon the gaping part of 
the suture, adhesion was effected, and a radical cure completed. 
The treatment lasted four months. In the second case, the pa- 
tient, a woman 28 years old, had already been operated upon 
unsuccessfully, and a cicatricial tissue, hard and thick, bordered 
the edges of the fistula, which was eight millimetres long. In 
this case also, two operations were necessary. 

M. Courty only revives the borders of the fistula, at the 
expense of the vaginal mucous membrane, carefully avoiding 
the vesical. For the deep sutures he uses Startin's needles, and 
for the superficial, Sims'. He leaves a sound constantly in the 
urethra, and by means of a canula pushed to the bottom of the 
vagina, has the cavity washed out twice a day with a lotion to 
prevent suppuration. The wires are withdrawn between the 
fifth and tenth days. 

Mistake between an Ovarian and Renal Cyst. 

The Gazette Hehdomadaire quotes a case of a mistake made 
between an ovarian and renal cyst by the distinguished Dr. 
Wells of London. A woman of 43 years presented herself at his 
hospital, to be treated for an abdominal tumor, that two ex- 
perienced physicians had already pronounced to be an ovarian 
cyst. They had refused to operate, however, because a loop of 
intestine was recognized as passing in front of the tumor. On 
the 4th of August, when Mr. Wells first saw the patient, the tumor 
had risen to the epigastrium, and the patient seemed threatened 
with suffocation. He punctured the cyst to her immediate relief, 
and the tumor and dull percussion sound entirely disappeared. 
Two months later, the woman returned to the hospital, with 
the tumor again filling all the abdomen. On the left of the 
umbilicus was recognized a hard band, which was supposed by 
some to be a loop of intestine, by others the Fallopian tube. 
The menstruation was regular; the urine contained mucus and 
epithelium, but no albumen. The abdomen was largely opened 
in the median line. The incision of the peritoneum revealed 
passing in front of the cyst, the transverse and descending colon, 



1 6 Mary Putnam Jacobi 

intimately adhering to the abdominal walls and also to the cyst; 
15 pints of gray purulent liquid were withdrawn from the cavity. 
The destruction of the adhesions revealed a second cyst, which 
yielded two pints of clear liquid. Finally, since it was impossible 
to destroy the deep adhesions, the cyst was left in place and the 
wound closed. The patient succumbed the next morning. At 
the autopsy the following state of things was manifest: Four 
pints of sanguinolent sertun and of coagula were effused in the 
peritoneum. The uterus and ovaries were perfectly healthy. The 
0ght kidney was hypertrophied, and much softened, a calculus 
of 40 centigrammes was found in the calix. The left kidney was 
converted into a cyst more voluminous than the head of a foetus, 
containing a single cavity divided by bridles, and whose walls 
were formed by the renal capsule. The parenchyma had 
completely degenerated and atrophied. 

A precisely analogous case occurred here the other day, at 
La Pitie, in the ward of M. Belrier. The patient was 48 years 
old, and feeble, and on this account it was decided that ovario- 
tomy was unadvisable, although an ovarian cyst was diagnosed 
without any hesitation. Tapping was followed by the complete 
collapse of the tumor, which, however, resumed its original 
dimensions in two or three weeks. At the time of the patient's 
death, two or three weeks after the operation, the cyst contained 
several quarts of liquid, and occupied all of one side of the abdo- 
men, from the iliac fossa to the hypochondrium. At the post- 
mortem, this tumor was found to be an enormous cyst of the 
kidney, whose entire parenchyma was destroyed, and only the 
capsule left, lined by a serous membrane of new formation, but 
of sufficient secreting power to reproduce the entire volume of 
liquid in the course of two or three weeks. 

Mr. Wells has profited by his mistake to make a more careful 
study of the points of diagnosis between renal and ovarian cysts, 
and has published some most valuable reflections. The diag- 
nosis, he says, should be based on the following circumstances: 

I St. Whenever a bridle of intestine is recognized as passing in 
front of the cyst, it is almost certainly renal, since the ovarian cysts 
push the entire intestinal mass of it against the vertebral column. 

2nd. The ascending colon would be found on the internal 
side of the right kidney ; the left is crossed from above downwards 
by the descending. 



Letters to the Medical Record 17 

3rd. The urine, which should be subjected to a microscopic 
examination, nearly always contains mucus, epithelium, pus or 
albumen, in cases of renal tumors, whilst the menstruation is 
not disturbed as it is in ovarian disease. (This latter circum- 
stance evidently cannot be relied upon in the numerous instances 
where the tumor is developed after the menopause.) 

4th. The bridle, on percussion, is found to be contracted 
like a cord, and is mobile. 

5th. In the case of ovarian cysts, the liquid often escapes 
by the Fallopian tube, after adhesions have been contracted, 
while in renal cysts the way of escape is by the ureter and bladder. 

6th. Renal tumors appear first in the hypochondria, and 
develop downwards; ovarian in the iliac fossa, and pass upwards. 

Mr. Wells concludes that henceforth no one need make a 
mistake between the two diseases. 

Cancer of the Kidney, etc. 

While speaking aboutrenal tumors, I must mention a highly 
interesting case at present in the service of M. Herard, at Lari- 
baissi^re, where an inverse mistake in the diagnosis was induced 
by the ambiguity of the symptoms. The subject, a woman of 
about 38, entered the ward the 31st of March, presenting an 
abdominal timior that occupied the left iliac fossa, and extended 
in front to the umbilicus, and behind to the spine. A smaller 
tumor was situated in a precisely similar manner at the right 
side. The patient had begun to suffer five months before her 
entrance, with severe pains in the renal and dorsal regions, which 
were presently followed by the development of the left tumor, 
which rapidly increased to its present size. The disease had 
attacked the right side about a month ago. The anterior border 
of the tumor could be felt distinctly in front; behind the limits 
were more vague. Clear percussion sound was obtained between 
the dulness of the tumor, and that proper to the spleen. Also, 
the mass did not continue into the inguinal region, or pass the 
median line, so that the idea of an ovarian disease was set aside. 
The position at the left of the principal mass put the liver out 
of the question, and the appearance of a similar tumor in the 
right renal region indicated that a symmetrical organ was in- 
vaded. Everything, therefore, led to the belief that the disease 
occupied the kidney, a belief (as I hasten to say) that so far 



1 8 Mary Putnam Jacobi 

nothing has contradicted. But the tumor presented quite dis- 
tinct fluctuation. The complexion of the patient, though pale 
and chalky, had no tint of special cachexia, and the diagnosis of 
renal dropsy (hydronephrose) was pronounced. A surgeon in con- 
sultation agreed in this opinion, and tapped the tumor. There 
issued, neither urine nor serous fluid, but a small quantity of juice, 
which, both to the naked eye and the microscope, was evidently 
cancerous. The greater part of the tumor was, after all, solid. 
The patient is still alive, and her condition is liable to great 
variations. For a long time after her entrance to the hospital 
she suffered almost continually from pain, which, finally, seemed 
to be relieved by subcutaneous injections of morphine. A week 
ago she was a great deal better, sat up, embroidered, felt quite 
at her ease, but a relapse has just occurred, and she is now about 
in the same state as when she entered. During the first weeks 
the tumor seemed to increase, but for the last six weeks it has 
been quite stationary. Since the tapping (which did not ma- 
terially diminish the size of the tumor) , the sensation of fluctua- 
tion has disappeared, and now the surface of the mass is more 
uneven, though never hard, or distinctly bosselated. The cancer 
is evidently an encephaloma. 

Contractibility of Muscular Fibre. 

Before closing my chronicle, I must tell you of some singular 
experiments that have just been made by M. Rouget upon the 
contractibility of muscular fibre. M. Rouget commenced his 
researches on the subject, by the study of the style of the vor- 
ticellus, where the muscle consists of a single fibre. This is 
elongated during life, but under the influence of excitants, or 
after the death of the animal, the spiral returns brusquely on 
itself, and is shortened four-fifths, being transformed into a 
spiral spring, pressed closely together. Experimenting subse- 
quently upon living animals, Rouget found that everything that 
interfered with the nutrition of the muscles, made them contract. 
If the main artery of a limb were tied, if galvanic excitement 
was continued incessantly, if the muscles were subjected to a 
continually increasing heat or to cold, the result was always the 
same, they contracted. When the contractions were too frequent, 
the myographion showed that the transverse lines repeatedly 
approached each other, could no longer separate, but remained, 



Letters to the Medical Record 19 

as it were, agglutinated. Rouget declares that the primitive 
muscular fibre is constituted by an elastic fibre twisted in a spiral, 
and that the transverse lines mark the curves of this spiral, and 
not the segmentations of a straight bundle of fibrillar elements, 
as usually maintained. The state of repose, the normal state 
of this spiral, is that of the approximation of its rings, which 
appears to the eye as the contraction of the muscle. The length- 
ening is the really active process, and can only occur during the 
vigor of life. The cadaveric rigidity of muscles is precisely the 
same phenomenon as that occurring when their vitality has been 
exhausted by heat or cold, or starved out by lack of food. When 
a muscular fibre shortens, it does so in virtue of its own elasticity, 
which triumphs over the vital force developed in the act of nutri- 
tion. This or any other force that excites motion in the muscles, 
at the moment that it ceases to act, is transformed into heat, 
and hence the rise of temperature observed in muscles entering 
into a state of contraction. 

Muscles do not contract in successive undulations or shocks, 
except at the beginning of the action of an external excitant, or 
when they are exhausted by fatigue. Contracted muscles seen 
under a microscope, are found to be perfectly motionless. When 
they contract by the will, there are no undulations even at the 
beginning of the period. 

The influence of this theory, which reverses the passive and 
active sides of muscular movement, upon tetanus, chorea, and 
all diseases of muscular activity, is easily perceived. But M. 
Rouget as yet attempts no pathological applications. 

Un joli mot, as the French say, in conclusion. You are 
familiar with the name of Charcot, I suppose, and of his intimacy 
with the distinguished surgeon, Vulpian. The two have so often 
published together, that their names are inextricably associated 
to the public ear. The other day a friend of Charcot's observed : 

"Charcot has been made happy this morning. He is the 
father of a son." 

"What," exclaimed a bystander, "Charcot and Vulpian?" 
But it was explained that this time it was Charcot, tout seul. 

The Origin of Modern Anaesthesia. 

I have not yet finished, for I must mention the compliment 
paid by the Gazette Hebdomadaire to the Medical Record, as 



20 Mary Putnam Jacobi 

"the most serious medical journal in the United States." When 
the Record ascribes the first (chronological) honor of chloroform 
to Dr. Wells, the Gazette thinks that the question is settled. 

P. C. M. 



Paris, August 19, 1867. 

To the Editor of the Medical Record. 

Sir — The School of Medicine held its annual closing cere- 
monies on the 14th. M. Behier pronounced an eloquent eulogy 
upon Rostan. On the 17th the amphitheatre of the Ecole was 
again filled to celebrate the opening of the International Medical 
Congress, where seven hundred physicians from all parts of the 
world, representing nearly all the celebrated physicians living, 
had gathered together. 

The International Medical Congress. 

The hemicircle was draped with the flags of all nations. The 
eagle of Prussia floated in the midst of the colors ot France, and 
the Turkish crescent fraternised with the banner of England. 
M. Bouillaud presided, supported on the right by M. Gavarret, 
on the left by M. Tardieu, and pronounced an eloquent address, 
whose feeling was responded to by every member of the great 
assembly. When the illustrious professor said, "I cannot con- 
template this scene without being profoundly moved; I feel my 
feeble powers fail to express the just sentiment of the occasion," 
all the audience replied by bravos the most sympathetic; and 
when the orator concluded, "Let us rise to salute these entwined 
flags, and then unite our hands as they are united, in sign of 
complete and cordial fraternization," the enthusiasm was at its 
height, and the amphitheatre resounded with a thunder of ap- 
plause. 

But alas ! having been at its height, it was all the more liable 
to fall. The day was very hot, and the old amphitheatre was 
constructed for other purposes than those of ventilation. The 
question of the day was tuberculization ; and after the reading of 
the first memoir, the audience began to reflect, to calculate that 
many more were to follow, that they were "in" for three or four 
hours at least. People grew restless and anxious. Presently 



Letters to the Medical Record 21 

every one was electrified with a voice, whose timbre, entirely 
exotic, pierced right through the decorum, of the assembly, 

"M. President, is it permitted to ask a question?" 

"Certainly; speak." 

"I am a stranger; I am a physician from Holland, and as a 
Hollander I have been invited to assist at the International 
Congress, but I find I have made some mistake; for in my 
opinion this is no congress, but a class, a school-room, where 
some doctors have come together to admire each other, and hold 
themselves up for admiration." 

Literally, that is what the honest Dutchman said. He 
spoke with all the traditional phlegm of his race; he scanned 
each word, and the ironical syllables fell into the midst of the 
"band of brothers" like so many bomb-shells. Of course there 
was confusion, and calls to order ; then, finally, the reading of the 
papers on tuberculization was resumed. 

The other questions that will occupy the Congress are as 
follows : 

Second Session. — Continuation of the discussion on tubercu- 
losis. Discussion on the influence of climates, races, and 
different social conditions upon menstruation in diverse countries. 

Third Session. — On the constitutional accidents which occa- 
sion death after surgical operations. 

Fourth Session. — Is it possible to propose to different govern- 
ments efficacious measures to restrain the propagation of venereal 
diseases? 

Fifth Session. — On the acclimatation of the races of Europe 
in warm countries. 

Sixth Session. — On the influence of alimentation upon the 
production of certain diseases in different countries. 

(The memoirs announced upon this question all relate to 
pellagra.) 

And in the same seance will be developed some considerations 
upon entozoa. 

This programme promises well, some of the topics being of 
extreme interest and importance, and only capable of being 
studied in the light of the experience of physicians of many 
nationalities. All the medical world that is not at the congress 
has gone into the country, whither we will follow them, and col- 
lect some gleanings from the rich harvest of the provincial socie- 



22 Mary Putnam Jacobi 

ties, which in intelligence and learning are not inferior to those 
of Paris. 

The Contagion of Cholera. 

The Imperial Society of Medicine at Lyons, in the sdance of 
the 15th of July, listened to a dissertation by M. Rodet, upon 
the capital question of the contagion of the cholera. M. Rodet, 
who occupies a middle ground between the non-contagionists 
and the contagionists, commenced by citing a certain number of 
facts that had been adduced by each party in proof of its theory. 
On the side of the first, four. In 1835, the vessel Ville de Mar- 
seille was stationed two or three miles from Toulon, where the 
cholera was then raging, and the crew had frequent intercourse 
with the infected city, yet not a person took the disease. In 183 1, 
among a hundred nurses and attendants upon cholera patients 
in the hospital at Cairo, not a single person took the cholera; 
eighty nurses in the hospital of Monsourah have enjoyed the same 
immunity; and among sixty at the hospital at Damiette, only 
one took the cholera. Again, at the Hospital of the Dey at 
Algiers, the immunity of the persons attached to the cholera 
wards was so great in 1865, that one might have supposed them 
to be asylums of refuge. Finally, in the Military Hospital of 
Constantinople, 1,488 cholera patients were received from the 
27th of January, 1855, to the 31st January, 1856, of whom 658 
died. Their clothes and linen were washed by the hospital 
attendants; the privies exhaled from time to time fetid emana- 
tions, which spread throughout the hospital, and even beyond 
its precincts; yet in spite of so many conditions favorable to 
contagion, the disease was not communicated to any other 
patient, or to any of the persons attached to the wards. 

It is noticeable, however, in connection with the first case 
cited, at Toulon, that although the crew of the Ville de Marseille 
was so remarkably spared, twelve physicians succumbed to the 
epidemic. In 1865, there perished in the same city six physi- 
cians, two apothecaries, ten nurses at the marine, and five at the 
military hospital, in all twenty-three persons connected with the 
care of the cholera patients. 

In these cases, however, the non-contagionists may still urge, 
that the victims were at the same time exposed to epidemic 
influence, so that it is impossible to tell what share contagion 



Letters to the Medical Record 23 

had in the infliction of the disease. This argument does not 
hold in regard to seven other cases quoted by M. Rodet, occur- 
ring during various epidemics, and one related in detail by M. 
Petiteau, that he observed last September. In all these cases 
the infection seemed to be directly transmitted by persons going 
from an infected to a healthy locality, was first communicated 
to persons with whom they came directly into contact, and 
thence from individual to individual, over a certain radius, after 
which the morbid influence seemed to be extinguished. In only 
one case was a wide-spread epidemic excited. In five of these 
eight cases the disease was imported by people who had visited 
the infected locality, merely during a few hours or days, and were 
attacked shortly after their return home, communicating the 
disease to those who nursed them. In M. Petiteau's case the 
attendants on the patient escaped, but after his death a drunken 
comrade, who persisted in passing all night by his corpse, em- 
bracing it, and committmg a thousand extravagances, was 
speedily smitten. Twelve cases followed this infection, of which 
six died. In the cases cited by Rodet, for the first, only the son 
and husband of the original patient died, while she recovered, 
and the disease went no further. In the second instance, only 
the mother of the patient was carried off, while he recovered. In 
the third, fourteen persons perished out of a population of 130 
inhabitants. In the fourth, there were thirty-one deaths in 
thirty-four days. The other three instances of infection men- 
tioned by Rodet were occasioned by the flight of persons from 
places where they had lived, for some time during the prevalence 
of the epidemic, into healthy localities. In the first case, a gen- 
eral epidemic was lighted up. In the second, all the members of 
a family living in different houses were successively attacked. 
In the third, twenty-seven persons were attacked, of whom 
twelve succumbed. 

M. Rodet, although attaching full importance to these facts, 
as proof of the communicability of cholera by direct contagion, 
is careful to point out that such influence cannot explain all the 
bizarre phenomena of epidemics, and that it is necessary to admit, 
over and above the focus of infection, a general cause which hov- 
ers over all the individuals placed in this focus, an epidemic 
cause, a qiiid divinuni or ignotum as has been so often repeated. 

The Medical Gazette of Algiers reviews a recent work by 



24 Mary Putnam Jacobi 

M. Jules Girette, where this question of the epidemic influence 
is treated on the largest scale. This writer, by the very title 
of his work, Civilization and the Cholera, betrays that his views 
are liable to be all rather biassed by the idea that belief in 
contagion must tend to barbarize nations, and hence ought to be 
discountenanced on moral grounds. It is rather unfortunate 
that this initial bias should be so perceptible, for it somewhat 
tends to shake the reader's confidence in the complete impar- 
tiality of the author's statements. Yet various circtmistances 
pointed out, concerning the march of the epidemic of 1865, along 
the shores of the Mediterranean, seem certainly difficult to 
reconcile with the theory of the perfect efficacy of quarantine. 
"Greece and Sicily isolated themselves completely, and escaped 
the cholera. But so also did Corsica, which continued to com- 
municate freely with the infected cities of Nice and Livourne, 
and only subjected vessels coming from Marseilles, where the 
epidemic was at its height, to a quarantine of three days. Salon- 
ica and Volo, unexpectedly exposed to the contagion, after a 
prolonged quarantine, nevertheless escaped. Neither Sarn- 
soum, nor Catourn, nor Dourgas, nor Varma were attacked by 
the cholera, although they were constantly visited by emigrant 
vessels. It scarcely touched Trebisond, traversed by hosts of 
fugitives en route for Persia. Yet all these ports had no other 
defence than a quarantine of from three to five days. At Malta, 
Bey rout, Dardanelles, and Odessa, the epidemic was communi- 
cated to the city by the lazaretto that professed to protect it. 
At Constantinople, a Turkish frigate evaded the quarantine, 
and imported the disease. Majorca, surrounded by a cordon 
sanitaire, attributed the cholera by which it was decimated, to 
some secret fraudulent importation, since no other cause could 
be discovered. The same with Alicant. At Enos the epidemic 
raged, and could be explained by no suspected communication. 
Trieste, spared up to the 28th of September, and believing itself 
secure behind a model lazaretto, awoke to find the cholera within 
its walls. Southampton, freely open to arrivals from Alexandria, 
did not register its first death from cholera until the 25th of 
September, nearly at the same time as Trieste, and two months 
after Marseilles." 

M. Girette, however, takes great pains to trace the march 
of the epidemic of 1865, from its cradle, among the hordes of pil- 



Letters to the Medical Record 25 

grims to Egypt. M. Jobert, however, sanitary physician on 
board the Arethusa, who reviews the book, lays much more stress 
than the author upon the fact that some new and peculiar atmos- 
pheric conditions, or epidemic capacity, must have prevailed at 
Eg^^pt during that year, since every year the pilgrims were in 
the habit of having the cholera at Hedjaz, but it was not com- 
municated beyond their own camp. M. Jobert quotes with 
especial emphasis the description given from personal observation 
by M. Girette, of the state of things at the temple of Withoba, 
at Punderpoor, where men and women were crowded together 
by thousands, in a narrow court, awaiting their turn to enter 
the temple. Inside the little stone temple the same, and worse; 
the emanations from the bodies of the worshippers condensed 
upon the statue of the god, and the moisture was regarded as a 
miraculous sweat! The resident physician at Punderpoor be- 
lieves that the first origin of the cholera is probably at this cele- 
brated shrine. 

To return for a moment to M. Rodet. He speaks hopefully 
of the good effects of the treatment suggested by Dr. Burg, and 
in 1865 experimented by M. Lisle, physician at the Insane Asylum 
at Marseilles. Upon the appearance of the epidemic in the 
asylum, M. Lisle had at first endeavored to combat its ravages 
by the ordinary method of diffusible stimulants. He lost twelve 
patients out of fourteen, a number much greater than the ordin- 
ary average, and whose excess is to be attributed to the much 
feebler resistance to the disease offered by the insane. Finally 
the servant of M. Lisle was attacked; he employed the same 
treatment, and with equal lack of success, for at the end of 
twenty -four hours all hope seemed to be lost. In this extremity 
he resolved to try Dr. Burg's prescription, and considerably to his 
surprise the woman recovered. He then applied the same treat- 
ment to the remaining patients in the wards, and the results 
surpassed his expectations. Among twenty-six men he ob- 
tained twenty-one recoveries, and among six women (including 
his servant), four; in all, twenty-five cures among thirty-two 
cases. 

The following is the formula for the remedy that obtained 
such unlooked-for success : 

Dissolve five per cent, of sulphate of copper in 150 grammes 
(about five ounces) of distilled water; and add to this 150 



26 Mary Putnam Jacob! 

grammes of sugared water, together with lo drops of Sydenham's 
laudanum. 

A Case of Osteomalacia. 

At the Society of Medical Sciences at Lyons, was recently 
presented by M, Verard, a most interesting case of osteomalacia. 
The patient, as usual, a woman, was thirty years old, and had 
been the victim of the disease for ten years at the time of her 
death, which occurred in an attempt at child-birth. I have been 
unable to find the details of the case as related by M. Verard, 
having only at hand a subsequent report upon the case, made 
by Dr. Berne, surgeon at La Charite at Lyons. 

In this report is only noticed, that the commencement of 
the disease had been characterized by sharp pains, which had 
been supposed to be rheumatismal ; that the pregnancy had, as 
usual, greatly accelerated the march of the disease; that the 
diseased bones presented were all highly porous; that in the 
spongy tissue, the osseous trabeculas had become rare, or had dis- 
appeared; the medullary spaces had united together, and in the 
hollow bones contributed to enlarge the medullary canal; that 
even in the cortical compact substance, the vascular canals were 
enlarged, and formed areolae, which uniting transformed it into 
a spongy tissue of large network; which indeed was so general 
that the compact tissue had almost disappeared, and there only 
remained the superficial layer, which, moreover, was infiltered 
by a yellow, fatty, medullary substance; that, besides, in the 
parts of the osseous system which were the most altered, were 
discovered numerous cells resembling pus globules. 

This last fact seems to confirm the opinion of Virchow, who 
ascribes osteomalacia to a parenchymatous inflammation, the 
immediate consequences of which are only an interstitial exuda- 
tion, but the remote result is the destruction of the osseous 
tissue. 

A chemical analysis of the bones was made, principally with 
a view of searching for lactic acid, and thus indirectly testing 
the theory' that ascribes the resorption of the lime salts to the 
presence of this agent. It was impossible to find lactic acid in 
the free state, for at the time the analysis was made, the bones 
had already submitted to maceration for several days in water 

» Of MM. Marchand, O. Schmidt, and Otto Weber. 



Letters to the Medical Record 27 

saturated with marine salt, and the acid, if present, would neces- 
sarily be dissolved. But some lactates might still be left. To 
settle the question, the ashes of the calcined bones were treated 
with water, thus losing a considerable portion of their weight 
(0.42 gr. out of 0.99 gr. for the spongy substance, and 0.23 gr. 
out of 1.73 gr. for the compact). The filtrated substances, pre- 
cipitated with nitrate of silver, gave 0.20 chloride of sodium in 
the first case, and o.io in the second. Remained 0.22 and 0.13 
of residue, in which, if anywhere, the lactates were contained. 
In this residue, dissolved in distilled water, the presence of an 
organic acid was presently proved by the addition of a few drops 
of nitric acid, then lime-water, which formed a precipitate, prov- 
ing that the nitric acid had found material to convert into oxalic 
acid, which produced an oxalate with the lime. Further exam- 
ination showed that the solution did not precipitate with bar)rta- 
water, had no action upon lime-water until it had been treated 
with nitric acid, and gave a white precipitate with concentrated 
acetate of zinc, whence the presence of lactic acid was conclu- 
sively proved. 

The usual disproportion between the organic and inorganic 
materials of the bones was also shown by the analysis. The 
proportion in 100 of the inorganic matter instead of being 64, 
the normal figure for compact bone, was 41, and in the spongy 
substance not more than 18. 

The proportion between the carbonates and phosphates re- 
mained the same, the former being one-tenth the weight of the 
latter. 

M. Verard very justly regretted that no experiments had 
been made to ascertain whether, in spite of the narrowness of 
the basin, the head of a foetus could not have been made to pass, 
in virtue of the softness of the bones. The antero-posterior 
diameter of the inferior strait only measured from a centimetre 
and a half to two centimetres; but the bones were so soft, that 
the first placed in the pelvic cavity easily forced a place for itself. 
Dr. Berne thought that in a similar case, at a moment of ac- 
couchement, before the obstetrician should address himself to 
the cesarean operation, he should seriously consider whether the 
pelvic basin were not susceptible of enlargement by dint of 
pressure. In the case in question, I am unfortunately unable to 
tell what was actually done. 



28 Mary Putnam Jacobi 

The Function of the Vascular Glands. 

At a recent seance of the Academy of Medicine in Belgium, 
Dr. Foisson read a paper, propounding a theory on the function 
of the vascular glands, that seems to mc much the most ingenious 
and complete of any that has ever been advanced concerning 
them. This theory carries out the suggestion made by Brous- 
sais, who assigned to the spleen the function of deviating the 
blood from the stomach; so the thymus and thyroid, a similar 
role for the respiratory organs. This idea, however, being based 
upon no serious proof, passed unperceived. But M. Foisson has 
greatly enlarged and strengthened it in his essay, of which I shall 
endeavor to give you an idea. 

The general theory of derivation is the following: All organs 
submitted to alternations of action and repose, require a greater 
amount of blood during the first than the second period. The 
variations thus necessitated in their circulation, are effected by 
an agency independent of the general circulation, namely, the 
appropriate vascular glands, that act by driving the blood away 
from the organs when they have no need of it. 

The only organs in adult life, engaged intermittently in 
active functions, are the muscles, stomach, brain, and uterus. 

The muscles, when acting separately, mutually derive the 
blood from one another, and when they act all together, the 
heart quickens its action, and sends the excess of blood required. 
Their variations, therefore, depend directly on the general circu- 
lation, and they have no need of special apparatus. 

But the stomach is essentially intermittent in its activity. 
The secretion of gastric juice evidently demands a large amount 
of blood, to judge from the size of the arteries distributed to its 
walls. During the intervals of digestion, these arteries are tor- 
tuous, and comparatively little blood passes through them. 
The blood from the coeliac axis being mainly distributed by the 
splenic artery to the spleen, the tortuousness of this splenic 
artery may be supposed to be unfolded at an opposite time from 
that in which the gastric arteries grow straight. 

The thyroid gland is the derivative reservoir for the blood 
going to the brain. This blood arrives at the thjToid from the 
superior thyroidien given off from the internal carotid — and the 
inferior thyroidien, that springs from the subclavian close by the 
origin of the vertebral, so that by a double route the circulation 



Letters to the Medical Record 29 

of the thyroid can affect that of the encephalon. In virtue of 
that same connection, between the thyroid and the brain, do 
persons affected with goitre so often become cretins; the exag- 
gerated development of the thyroid interferes with the nutrition 
to the brain, and the more important organ is actually starved 
out by the fraud of the less, which seizes its supplies en route. 
Finally, for the uterus, the mammary glands perform the office 
of derivation, and, after parturition, when the uterus must 
retract, and has no further need of the expensive nourishment 
upon which it has subsisted during pregnancy, the epigastric 
arteries, prepared for the task by the development they have 
experienced during the last months of this period, intercept the 
supply of blood going to the uterus, and convey it to the glands, 
by means of their anastomoses with the mammary arteries. 
Among animals in whom the mammary glands are abdominal, 
the epigastric artery supplies them directly. To this extremely 
suggestive interpretation of the well-known facts of the case, one 
difficulty may be addressed. If the extra nutrition of the uterus 
and mammary glands is carried on at alternate periods, how 
does it happen that the glands increase during pregnancy ? This 
fact, however, is really provided for by the theory which admits 
that the satellite organs do increase coincidently with their 
principals, if only for the sake of being at hand, and in good 
condition, to receive the brunt of their circulation when the 
functions of the principal organ is intermittent; but that in 
addition to this parallelism of development, comes the alterna- 
tive, or contrast, at the moment when the principal organ sub- 
sides into inactivity, and the satellite starts into full activity. 

For explanation of the office of the thymus gland and supra- 
renal capsules, the theory is identical, but applied as it were in 
an inverted fashion as respects chronological order. The lungs 
and kidneys do not function at alP during foetal life, and hence 
have need of only so much nutritive fluid as is required for their 
growth. But as they begin to act at the very moment of birth, 
the new supplies necessary for the maintenance of their functions 
must be stored up close at hand, ready to be turned into their 
future channels. For this purpose the thymus gland and supra- 
renal capsules are contrived. The blood during foetal life is 

' This is the remark of the author. But I believe it is not strictly correct 
for the kidneys, since the bladder is found to contain urine before birth. 



30 Mary Putnam Jacobi 

directed towards them, as it were next door, but at the moment 
of birth the current is turned into the neighboring arteries, and 
from that moment the foetal organs begin to waste and gradually 
disappear. 

The thyroid gland also, though in action throughout life, 
is much required during infancy, since the brain at that period, 
as far as regards its intellectual functions, is in a quiescent or at 
least passive state, consequently the thyroid gland of children is 
proportionately much larger than in adults. 

M. Foisson refers to the characteristics common to the 
structure of all the vascular glands, as tending to confirm his 
theory. Huschke and Kolliker agree in recognizing in all these 
organs the existence of: 

1. A foundation system of trabeculas, serving for a support 
to the vessels. 

2. Vesicular cavities occupying the interstices left between 
the trabeculae. 

3. The presence in the cavities of a liquid charged with glo- 
bules, and the absence of any efferent canal. Nothing in this 
structure suggests the idea of a secretion appropriated to the 
perfectionment of the blood or lymph, while it is on the contrary 
marvellously adapted for the purposes of derivation. 

The entire theory is resumed in the following propositions : 

1 . All the organs of the economy consume during the periods 
of their activity an amount of blood more considerable than that 
required in repose. 

2. In the normal state, the heart sends at each moment the 
same quantity of blood in every branch of the arterial tree. 

3. The blood which arrives at organs in excess during their 
period of repose, is received by special organs called derivators. 

4. The function of derivation may be performed without 
the intervention of an organ exclusively devoted to the task, as 
in the case of the mammary glands. 

5. Every organ whose function is intermittent, possesses 
an apparatus for derivation. 

6. Derivation is not only arterial, but sometimes venous, 
as when the spleen receives the trop plein from the portal vein, or 
the thyroid, during muscular exertion, from the engorged jugulars. 

7. Derivation is a complementary function of the circula- 
tion, and necessary to a regular distribution of the materials of 



Letters to the Medical Record 31 

nutrition and secretion. At the same time it is not absolutely 
essential to life, so that in the lower animals any of the vascular 
glands may be extirpated with impunity. 

8. Derivation is explained by the following law of physics: 
When a pipe traversed by a fluid is divided into two branches, 
that of the two in which the current is the most rapid receives 
a ^eater quantity of liquid than the other. 

This theory is so perfectly captivating to me, that as yet I 
have not been able to imagine any serious objection to its sound- 
ness. Perhaps you or your readers may be more critical, and I 
submit it to your judgment. 

Union by First Intention after Lithotomy. 

Professor Bouisson, of Montpellier, is at present writing a 
series of articles in the Montpellier Medicale, upon union of the 
wound by first intention after the operation of lithotomy. The 
Professor not merely believes this to be possible, and in his first 
paper adduces four cases in proof of his assertion, but engages 
to show how this very desirable result can be secured. Of these 
four cases, the first was that of a young man who had been treated 
for some time with elastic bougies, in the hope of sufficiently 
dilating the urethra to admit of the operation of lithotrity. All 
at once, however, the patient became unquiet and irritable; an 
obstinate spasmodic condition of the canal joined itself to the 
organic retraction, and forced the surgeon to abandon all hope 
of crushing the calculus, and an operation for lithotomy was 
decided upon. Owing to the presumed smallness of the stone, 
the median incision was selected. The operation was performed 
on the 1 6th of December, and encountered no serious difficulties. 
An incision of three centimetres practised on the median line of 
the perineum easily attained the urethra. After division of the 
cutaneous and cellular layers, the membranous portion being 
directly divided, the length of the left edge of the catheter which 
had been introduced in the urinary canal to serve as a guide, a 
lithotome was introduced, the catheter withdrawn, the finger, 
gorget, and forceps successively introduced into the bladder, and 
the calculus seized and extracted. 

The calculus was spheroidal, with irregular surface, so com- 
pact and hard that the operation of lithotrity would have been 
very difficult. A vesical injection terminated the operation, 



32 Mary Putnam Jacobi 

which had been performed with the assistance of chloroform. 
The knees of the patient were then drawn together, and main- 
tained in an elevated position by a cushion placed underneath; 
a calming and diffusible draught was administered; the day 
passed without fever or vesical pain; the patient vomited twice; 
in the evening a little urine escaped by the natural passage. 
The next day reddish urine was passed naturally, also a ver>' 
small amount escaped at the wound, whose appearance was 
good. During the two following days also the local and general 
phenomena were satisfactory; the urine nearly entirely passed 
by the urethra. The wound closed without suppuration, and by 
the eighth day was completely cicatrized by first intention. The 
cure was permanent. 

In the second operation performed by M. Bouisson, the 
patient was sixty-four years old, and the bladder contained six 
calculi and was completely paralyzed. After the operation, 
whose details I will not repeat, the persistent retention of urine, 
which did not even escape by the wound, rendered it necessary to 
leave a sound permanently in the bladder, for the accumulation 
caus-ed much pain and suffering to the patient. By this means 
also the urine was completely turned away from the wound, a 
circumstance which undoubtedly favored its union, which was 
effected in six days, by first intention, without any trace of in- 
flammation or infiltration. In this case also the median incision 
had been practised. The third, the same form of the operation. 
The subject was sixteen years old; the calculus, though hard and 
voluminous, was ovoid, and presented itself to the forceps by its 
most favorable diameter, so that it was extracted without dif- 
ficulty. After the operation, the adduction of the thighs was 
secured by means of an apparatus, so that the lips of the wound 
were brought in contact, and the dorsal decubitus strictly en- 
joined. The first day only the urine escaped by the wound; after 
that the patient was able to urinate voluntarily. Even after 
the subsidence of the swelling around the lips of the wound, 
which might at first have opposed the escape of the urine, that 
liquid continued to traverse the natural passages, and owing to 
this fortunate circumstance the wound was cicatrized by the 
sixth day. Neither infiltration, nor ecchymosis, nor suppuration 
supervened, and the cicatrix remained perfectly solid. The 
fourth operation, with the medio-lateral incision, was performed 



Letters to the Medical Record 33 

on a child of six years old, who had suffered from painful micturi- 
tion from the age of two years. In this case the first sounding 
had failed to discover the calculus, and although that was dis- 
tinctly perceived at the second examination, it seemed again to 
disappear at the moment of the operation. Nevertheless, M. 
Bouisson made the incision. The posterior radius of the pros- 
tate gland seemed so short, in consequence of the flattening of 
this organ, that, having practised the median section of the skin 
as far as the urethra, M. Bouisson judged it prudent to incline 
the lithotome in the direction of the oblique radius of the prostate, 
in order to avoid the rectum, and to limit this oblique section to 
the gland, so that the incision represented a broken line whose 
first part was straight, and the second oblique. This opening, 
more than sufficient for the extraction of the calculus, gave issue 
to a certain quantity of urine, which carried the stone along with 
it into the very grasp of the forceps. The calculus was the 
volume and shape of an olive; mammillated, reddish-yellow, and 
composed of uric acid. The whole operation only occupied three 
minutes from the moment of the incision to the extraction of the 
stone. 

In consequence of the inclination of the lithotome, a branch 
of the perineal artery had been divided, giving rise to consider- 
able haemorrhage, an accident that had been entirely avoided in 
the other operations. The haemorrhage was arrested by torsion 
of the vessel, but returned some hours after the operation, to be 
finally vanquished by compression and the application of ice. 
This was the only notable effect of the operation. The urine 
escaped by the wound during the evening and in the night; but 
after the first day the passage of urine ceased to be continual, 
and came under the influence of vesical contraction. Towards 
the end of this day a part of the urine passed by the urethra, and 
from the fourth day no more escaped from the wound, which 
united without suppuration, and without the occurrence of 
either sanguine or urinary infiltration. By the eighth day the 
cicatrization was complete. 

All these cures were obtained by the perineal operation. 
M. Bouisson thinks that such happy results could rarely be 
achieved when the hypogastric incision was practised. In suc- 
ceeding papers he hopes to develop further . views suggested by 
the interesting observations of which I have related the summary. 



34 Mary Putnam Jacob! 

New Apparatus for Irrigation of the Eye. 

Dr. Amable Cade, of Saint Andeal, also makes a communica- 
tion to the Montpellier Medicale, concerning a new apparatus 
devised by himself for securing continual irrigation of the eye 
after the operation for cataract. This is composed : 

1. Of a hemispherical reservoir, of a capacity of nearly 
a quart, with an opening at the top, and capable of being sus- 
pended over the head of the patient. 

2. Two supra-ocular recipients, of lozenge shape, each 
furnished with two little handles, destined either to fix the 
apparatus before the eyes by the aid of a circular band, or to 
keep in place the two recipients when both eyes have been operat- 
ed the same day. Their posterior side is made of gold-beater's 
skin, which ought to be placed in immediate contact with the 
closed eyelids. 

3. Two tubes, communicating between the reservoir and 
the recipients. These tubes are furnished with screw joints, 
which permit the suppression of one of the recipients when only 
one eye is operated. 

4. Little pieces of sponge loosely introduced in the com- 
municating tubes, to prevent the passage of the water, except 
drop by drop, every second in ordinary cases. These sponges 
may be removed in case of imminent danger from violent inflam- 
mation, when a rapid current of cold water is needed. 

5. Two discharging tubes, a yard and a half in length, 
destined to conduct the irrigating fluid from the recipients to a 
vase placed by the bedside. 

By means of this apparatus. Dr. Cade has already performed 
eight operations for cataract with the most complete success, 
in some cases warding off a commencing phlegmonous inflamma- 
tion, that threatened to become a terrible complication. 

P. C. M. 

The International Medical Congress. 

Paris, Sept. 9. 
To the Editor of the Medical Record. 

Sir — Now that the International Medical Congress has come 
to an end, it may not be inappropriate to review its proceedings, 
and endeavor to form an estimate of its results. 

This task cannot fail to disappoint. It is acknowledged on 



Letters to the Medical Record 35 

all hands that the Congress was ill-organized, the programme 
"arranged without sufficient tact, and the legitimate aims of the 
discussions almost entirely lost sight of. Evidently the great 
advantage to be gained by the discussions of an assembly of 
physicians from all parts of the world would be, that the con- 
tingent of information furnished by each should represent some- 
thing peculiar to his country or school. Data, often painfully 
gleaned from the records of travellers, would be collected in 
abundance by medical observers resident on the spot, and offered 
to enrich the common treasure. Moreover, celebrated men, 
who had hitherto talked to each other across seas, and through 
the medium of books, would meet face to face, would familiarly 
converse with each other on the mighty labors by which their 
names, their fatherland, had been rendered illustrious, and 
derive mutual refreshment from the rare intercourse. 

All this I say might have been expected. But the expecta- 
tion has been very imperfectly fulfilled. In the first place only 
inadequate provision was made in different countries to send 
such men as should most justly represent the actual condition 
of national science. There should have been official delegates 
from the principal universities, who should have been distin- 
guished from the crowd of mediocrities who might choose to 
attend, but who should not be mistaken for such representatives. 
From lack of such precaution, a multitude of opinions were 
advanced which were entirely undeserving the sanction of so 
solemn an occasion as this professed to be. Any one could speak, 
and any one did speak; and, as a rule, the more distinguished 
visitors held their tongues. 

Not a word from Virchow or Graefe, who were both present; 
not a word from Bennett or Simpson. Indeed only two English- 
men are on record as having spoken, and not a single American. 
The debates were chiefly maintained by the French and Italians. 
This was probably in part owing to the very imperfect knowledge 
of French that prevails among us Anglo-Saxons, especially the 
Americans, and which, as I have had quite frequent occasion to 
observe, seriously interferes with the benefit they are able to 
derive from a few months' visit to Paris. But the silence also 
resulted, in all probability, from the fact that few had prepared 
themselves for a sufficiently long time in advance; as a conse- 
quence, the topics for discussion were developed in the most 



36 Mary Putnam Jacobi 

unequal and irregular manner. The minute anatomy of tuber- 
culosis occupied two or three sessions, in which nearly all the 
speakers were French, who revived old disputes without report- 
ing any researches made especially for the Congress. On the 
other hand, the three questions that seemed most peculiarly 
adapted for international discussion — the influence of various 
climates upon menstruation ; the problem of acclimation ; and the 
influence of alimentation — were only touched upon in the most 
cursory manner. As a whole, therefore, the Congress cannot 
be said to have arrived at any valuable result. Nevertheless, 
two of the discussions — on the treatment necessary to prevent 
purulent infection after surgical operations, and on measures 
to be recommended to the governments of various countries to 
arrest the spread of syphilitic diseases — ^were exceedingly inter- 
esting; and in all the seances, various topics were incidentally 
developed that are quite worth recording. I shall endeavor to 
mention some of the principal, beginning with those which occu- 
pied the least time and attention. 

The communications made on the subject of alimentation 
were, in accordance with the programme, all written in reference 
to pellagra. M. Bouchut has found on grains of wheat spoiled 
by the damp, a fungus very similar to that found in the same 
circumstances on the maize, to the consumption of which pellagra 
is generally attributed. He proposes to name this fungus 
sporisorium tritici. To obtain it, it is only necessary to place 
some wheat in a jar, and keep it damp. 

M. Demaria believes that pellagra is not dependent on an 
accidental poisoning, but is a constitutional neurosis, dependent 
on hereditary influences and poor food. 

The communications of M. Dropsy, of Cracovia, concerning 
the Polish Jews, and Mr. Kingston on the Anglo-Canadians, 
presented in the course of the discussion on tuberculosis, touch 
on a subject of more widely spread interest than the poison of the 
maize. Each tends to prove the enormous influence of animal 
food upon the preservation of health, especially from the ravages 
of phthisis. At Cracovia, the peasants are all healthy and 
robust, living much upon animal food. The Jews scarcely spend 
more than two sous a day for their nourishment, and never eat 
meat. Consumption makes such ravages among them that the 
race threatens to die out. In the same way in Canada, the 



Letters to the Medical Record 37 

French Canadians, who eat meat in excess, often three or four 
times a day, are declared by Mr. Kingston (an Englishman) to 
be a superb race of people; while their English neighbors, who 
live much more soberly, are infinitely more subject to tubercu- 
lous disease. 

The question of acclimation was as much restricted as that 
of the influence of food, being limited to the investigation of the 
conditions necessary for acclimating Europeans in warm coun- 
tries. M. Simonot read an interesting memoir on the subject. 
For him the difficulty did not arise from the heat of the climate, 
but the poisonous influence of miasm. Wherever that could not 
be destroyed, it was useless to expect to make permanent homes 
for white families. 

M. Lombard, not adhering strictly to the question, com- 
municated the result of researches on the laws of mortality in 
Europe, according to atmospheric influences. According to 
these, winter and spring is the most sickly season for all the north 
and centre of Europe, while the southern countries enjoy their 
excess of mortality in summer and autumn. In Europe, miasm 
still continues to be one of the most powerful agents influencing 
mortality, and it is an agent which in this country it is in the 
power of man to remove. 

A nimiber of carefully prepared memoirs on the question of 
menstruation were communicated; but, as most of them consisted 
mainly of statistical tables, they could not be read. The sta- 
tistics that were read, by M. Lagneau and M. Joulin, accord very 
well with the established law, in virtue of which menstruation is 
known to be precocious in warm climates, and retarded in cold. 
In English India, the average age for the establishment of puberty 
is twelve years and six months. In Norway, sixteen years and 
four months. The supposed differences between different cities of 
France is shown to be trifling, Marseilles being only six months 
earlier than Paris. 

Mr. Robert Cowie has made some curious researches upon 
menstruation in the Shetland Islands, and its connection with 
longevity. In this locality the menses are established at the 
same age as in Great Britain, while the menopause, instead of 
occurring at forty-five or forty-six years, is deferred to a period 
varying from forty-eight to fifty-four years, fifty-one being the 
average. In connection with this, Mr. Cowie notices a consid- 



38 Mary Putnam Jacobi 

erable difference in the rate of mortality, as shown by the 
following table: 

Sheltand Islands Scotland 

Above 70 years = 33.55 per 100. 18.25 per 100. 

" 80 " = 20.00 " 7.05 " 

" 90 " = 5.03 " 1. 00 " 

From 95 to 105 years = 2.68 per 100. 0.29 " 

The discussion on tuberculosis was divided into three parts, 
severally referring to its pathological anatomy, its prevalence in 
different climates, and its treatment. Of these, the first received 
much the most attention, not because of its superior importance, 
but because it happens to be extremely d la mode at the moment, 
and more speakers had something to say on it. The debates 
touched on the following questions: First, the specificity of 
the tubercle; second, its identity with the products of inflamma- 
tion; third, the precise seat of the granular deposit; fourth, the 
relation of the yellow degeneration to the gray or crude tubercle; 
fifth, and finally, two or three peculiar and rather bizarre opinions 
were advanced which had no relation with any of these points. 

The question of the specificity of the tubercular deposit may 
be variously regarded. A special anatomical element may be 
sought, as characteristic of tubercle, but such an attempt was 
universally pronounced to be chimerical. On the specific char- 
acter of the tuberculous product, either the gray or the cheesy 
may be attacked or defended, together or separately. Such a 
combat occurred, and was marked by a diversity of arguments, 
in support of a diversity of theories. Professor Crocq of Brussels, 
and M. Lebert, assimilate completely the tuberculous process to 
the inflammatory. M. Crocq began b>- declaring that the cellules 
of the gray granulation could be compared to nothing but the 
cellules oi the lymph and lymphatic glands, the white globules of 
the blood, of mucus, and of pus; in other words, leucocytes, 
among which he did not hesitate to class them. In the granula- 
tions, these leucocytes are distinguished from pus, chiefly by the 
absence of intercellular substance; are small, because bathed by 
no liquid, and have only a single nucleus, on account of their low 
vitality. These leucocytes arise from the epithelial cells, or 
those of the connective tissue, and submit ultimately to fatty 
degeneration, etc. 



Letters to the Medical Record 39 

The phenomena successively exhibited in the formation of 
these leucocytes, are identical with those of the cellular elements 
of inflamed tissues. When an organ is examined in which 
tubercles are developing, it is found strewn with vascular patches. 
Sometimes the centre is already consistent and elastic, and at 
this centre the tubercle is gradually formed by exudation, since 
vascularization and repletion of the tissues by matters destined 
to be exuded, is common to inflammation and tubercular forma- 
tion. Moreover, in inflammation the cellular elements absorb 
new material, swell, become opaque, and finally give birth to 
new generations of cells similar to the leucocytes. These, either 
in the tubercle or inflammation, have four destinations. First, 
they are destroyed, and their materials reabsorbed; second, they 
are transformed into new connective cells; third, they swim in an 
intercellular liquid, and constitute pus; fourth, they undergo the 
fatty degeneration. 

It results from these considerations (concludes M. Crocq), 
that tuberculization is by no means a specific disease, recognizing 
a vice of the blood for cause, but an affection of the same order 
as inflammations, and should be combated, like other phleg- 
masias, by antiphlogistics and revulsives. 

Lebert's views are substantially the same, but are based on 
inferences derived from certain experiments made upon animals 
by injections of various substances under the skin. In eleven 
instances were used the products of chronic pneumonia, chronic 
adenitis apparently tuberculous, and tuberculous granulations 
of the lungs; two experiments with injections of pus; nine, the 
products of expectoration and of pulmonary caverns; ten in- 
jections of charcoal or mercury were made into the jugular vein. 

The charcoal produced little emboli, followed by cellular 
hyperplasma, little granulations, and even multiplication of the 
epithelial cells and those of the connective tissue. The mercury 
provoked, besides, an inflammation of the vessels; here also, 
however, cellular hyperplasma, in the form of little granulations, 
and, when the irritation had reached a high degree, formation of 
solid inflammatory foci which ultimately suppurated and pro- 
duced caverns. 

The inoculation of morbid products excited a more severe 
local irritation, and also numerous granulations in different 
organs. 



40 Mary Putnam Jacobi 

Hence, for Lebert, the tubercle strictly resembling the granu- 
lation thus artificially created, is a product eminently hyper- 
plastic, and cannot be classed with accidental products properly 
so called. 

After this exposition of the pure inflammatory doctrine of 
tuberculization, Herard and Cornil rushed to the defence of their 
theory, which may be called modified inflammatory. For them, 
the gray granulation is the only characteristic lesion of tubercu- 
losis which excites an inflammation, whose degeneration consti- 
tutes the so-called cheesy tubercle. Neither of these champions 
undertook the task of rebutting the views of Crocq or Lebert, 
but each addressed himself to that side of the doctrine which 
touched upon, and was contradicted by, that of M. Villemain. 
This physician has recently made some remarkable experiments 
on the inoculation of tubercle, and has succeeded in thus convey- 
ing the disease to rabbits. vSo far, his experiments tended to 
confirm (at least without the criticism afforded by those of 
Lebert) the doctrine of the specificity of the tubercular deposit. 
But, proceeding further, he professes to have obtained gray granu- 
lations, after inoculation with the yellow cheesy matter. In con- 
sequence of this, he renounced the views he had previously held 
in regard to that substance, and, no longer believing it to be a 
secondary inflammation, he concluded it to be a more advanced 
stage of the crude tubercle, thus returning frankly to the ideas of 
Laennec. Herard replied that this cheesy pneumonia {pneii- 
mome caseeuse) might be sufficiently stamped with the character 
of the granulation by which it was caused, to serve as material 
for infection; but such did not prove that it was identical with 
the granulation which could often be found in its midst, little 
changed. 

M. Cornil attacked Villemain on another point, namely, in 
regard to the seat of the granulation. Villemain, in a memoir 
of some length, read at the first session of the Congress, declared 
that the greater number of granulations occupy the air- vesicles, 
herein again coinciding with Laennec. At the beginning of his 
researches, he had considered the contents of the alveoli as a 
product belonging to the pulmonary epithelium, and distinct 
from the granulation, which is the view actually held by Herard 
and Cornil. But subsequently, M. Villemain became convinced 
that the membrane of separation between the alveoli was not 



Letters to the Medical Record 41 

homogeneous, but contained a special element identical in 
structure with the connective tissue. In this tissue were de- 
posited the greater number of the granulations. He considers 
the existence of an epithelial layer at the internal surface of the 
alveoli to be extremely problematical. 

Hence, he does not believe that the elements constituting the 
catarrhal or cheesy pneumonia are derived from epithelial cells, 
but from the nucleated cells of the membrane separating the 
alveoli. Being much crowded, these cells sometimes assume 
plane surfaces from pressure, so as to resemble epithelium; but 
they are never soldered together. 

M. Villemain admits that the initial stages of tubercle re- 
semble those of inflammation, inasmuch as the two external 
zones of the three that constitute a tuberculous nodosity, repre- 
sent cells in different stages of development; but the two 
processes are to be distinguished by the terminations, which for 
inflammation is pus, for tubercle fatty degeneration. The 
similarity between the anatomical elements of these two states 
is, as M. Villemain justly thinks, no reason for identifying 
them. 

M. Cornil denied point-blank that the tubercle was developed 
anywhere but in the lymphatic or adventitious tunic of the 
blood-vessels, especially at their bifurcation. This phenomenon 
(in tuberculization of the pia mater) is accompanied by two 
others: ist. The multiplication of similar elements in the con- 
nective tissue of the pia mater which surrounds the diseased 
vessel; 2d. The coagulation of the blood, and the retrograde 
metamorphosis of the fibrine and blood-globules. 

M. Cornil admits that in the lungs there is a development of 
elements in the interalveolar membrane. But, besides, he 
insists that the large pavement cells, perfectly free, measuring 
0.015, are really epithelial, and cannot be confounded with the 
elements of the connective tissue, which are small, 0.004, agglu- 
tinated, intimately united by a homogeneous and granular sub- 
stance. The first constitute the tuberculous pneumonia; the 
second the granulation. 

A Hungarian physician. Dr. Bakody, warmly supported the 
views of Cornil. He moreover suggested that the tubercle 
developed especially in the simmiit of the lungs, because there 
the respiratory movements are less extensive, and the lungs can- 



42 Mary Putnam Jacobi 

not readily reject the mass of cells which form in the alveoli in 

consequence of inflammatory irritation. 

The question concerning tuberculization in different coun- 
tries and circumstances was then taken up. M. Marmisse read 
a memoir upon the influence of this disease on the mortality at 
Bordeaux- The influence of hygienic conditions is indicated by 
terribly eloquent figures. Among 1,000 poor people registered 
at the Bureau de Bienfaisance, 625 die of phthisis, while the 
rich classes only yielded a tribute of 87 on 1,000 to this formidable 
disease. 

I have already quoted M. Dropsy's remarks on the Jews in 
Poland, and Mr. Kingston's on the English in Canada. Dr. 
Homan, of Christiania, read a memoir on the disease in Norway, 
and its distribution in different sections of the country. The 
proportion of deaths from tuberculous diseases in Norway is 
about 162 in 1,000. The variations in different districts are from 
79 to 226 per 1,000. Sometimes a great difference is observed 
between two neighboring districts, which cannot, then, be re- 
ferred to difference of climate. Dr. Homan invokes syphilis as 
a powerful agent to explain this difference. The capital question 
of the treatment of phthisis received no new light. 

I must not forget to mention, among the opinions independ- 
ently broached, that of M. Empis, who invents a new disease 
called granulic, distinct from tuberculosis; and of a physician 
whose name escapes me, who declares the cause of tubercle to 
be excessive pressure in the blood-vessels, whereby the colloid 
matters in the blood are exuded in the form of granulations. 

The second great question, on the prevention of accidents 
after surgical operations, was developed with much animation. 
Two principal opinions obtained : one the perfect efficacy of local 
treatment, the other the importance of minute constitutional 
care. 

One of the most interesting memoirs read in support of the 
first theory was that of Professor Bourgade, of Clermont-Ferrand, 
on the employment of perchloride of iron. The capital fact 
from which the Professor reasons is the different effect produced 
by wounds made with a bistoury or with caustic. The latter 
are habitually innocuous; the former often followed by serious 
accidents of infection. Some surgeons have sought on this 
account to substitute the caustic for the bistoury; but that is 



Letters to the Medical Record 43 

impossible in a large number of cases, and the bistoury will 
always remain the surgical instrument par excellence. The 
problem is, therefore, to reduce the wound made by it to the same 
conditions as that produced by the caustic. This, according to 
M. Bourgade, is accomplished by means of the perchloride of 
iron, which combines intimately with the tissues, and forms over 
the wound a kind of magma solid and adherent, a species of 
plastic cuirass, which resembles both a coagulvun and an eschar, 
which becomes hard and resistant, and only begins to separate 
by suppuration, the sixth, eighth, or tenth day after the opera- 
tion. The following is the method for its application : When the 
operation is finished, and the arteries suitably tied, the wound 
should be washed and dried with the greatest care; and when 
the flow of blood is well arrested, the whole surface is covered 
with lint saturated in a solution of perchloride of iron at thirty 
degrees. It is essential that all parts of the wound, bones, 
muscles, cellular tissue, etc., receive the direct action of the 
liquid. The whole is covered with moistened lint. 

When the tampons of lint fall, they show a blackish surface, 
covered with a thin eschar, which gradually detaches itself, 
revealing a pink wound in very good condition, already covered 
with fleshy granulations. 

This method, of course, is only adapted to wounds uniting 
by second intention; but, in M. Bourgade's opinion, that is the 
only union possible in hospitals. Several surgeons expressed the 
opinion that the attempt to obtain union by first intention was 
rapidly being abandoned. The perchloride has been applied in 
95 operations, all followed with success. 

The accidents that are guarded against by the perchloride are 
more especially purulent and putrid infection, phlebitis, an- 
geioleucitis, osteomyelitis, and consecutive haemorrhages. 

The perchloride is supposed to act by a light cauterization of 
the bleeding surfaces, and by effecting a solid coagulation even in 
the interior of the veins. There results an adhesive and obliter- 
ating phlebitis, which prevents the suppurative phlebitis, and 
opposes the absorption of morbid elements. 

M. Barbosa, delegate from the Portugal government, read 
some extracts from an important statistical memoir on the 
operations practised for the last twelve years in the hospital St. 
Joseph, at Lisbon. They were quite favorable — only 59 deaths 



44 Mary Putnam Jacob! 

among 243 amputations of limbs; among these, 62 amputations 
of the thigh, which gave 29 deaths. 

M. Barbosa lays great stress upon the good hygienic condi- 
tions of the wards, ventilation, and cleanliness. He adopts the 
circular method for amputation, and always dresses the wound 
with lint dipped in alcohol saturated with camphor, an ancient 
custom in Portugal. 

Professor Gosselin followed Barbosa in attaching much more 
importance to these circumstances of hygiene than to the local 
dressing. He takes especial pains with the morale of his patients, 
endeavoring gradually to accustom them to the idea of the opera- 
tion, allowing them, whenever it be possible, to name the day, 
always securing them from pain by the use of chloroform, etc. 
He is also careful to remove the patient as far as possible from 
cases of erysipelas, etc., which, unfortunately at La Piti^, cannot 
always be very far. After the operation, he is especially careful 
to avoid doing anything to cause pain. Never places any ap- 
paratus on the stump which will render it necessary to lower or 
raise it; does not attempt to draw together the edges of the 
wound, and rejects the use of alcohol in the dressing to avoid pain; 
places the patients on a mechanical bed, which allows them to be 
moved without suffering. By these precautions, out of 48 
amputations he succeeded in saving 29 patients, a mortality 
of 39 on 100. Of the 19 deaths, 10 only were by purulent 
infection. 

As an instance of the disastrous influence of moral shock, 
M. Gosselin cites the case of a patient who was doing well, when 
he heard that his wife had become insane and was at the Sal- 
petri^re. Very soon afterward he began to shiver, and fell a 
victim to purulent infection. 

M. Verneuil, the distinguished surgeon at Lariboisidre, 
especially occupied himself with the consideration of the previous 
health of the patient. The influence of diseases, manifest or 
latent, of the kidneys and lungs, of drunkenness, miasm, etc., is 
constantly proved by the unfortunate results of the best con- 
ducted operations. M. Verneuil thinks that erysipelas more 
frequently occurs in individuals with the herpetic or arthritic 
diathesis. 

M. Labat attached less importance to previous or coincident 
diseases, and agreed with M. Bourgade in the attention needed 



Letters to the Medical Record 45 

for the local conditions of the wound. He lays down several 
rules as follows: 

1. Never attempt to obtain immediate union except when 
the wound is shallow, the texture of the tissues uniform, the 
opposed surfaces can be maintained in contact as well as the 
edges, and the tissues have not been too profoundly bruised. 

2. Carefully avoid all conditions which may lead to the 
alteration of the fluids, and their sojourn near the mouths of the 
veins. 

3. Favor the draining of fluids by a tube or other means, 
establishing a canal from one end of the wound to the other. 

4. Avoid the employment of all irritating substances, especi- 
ally in regions abundantly provided with l5rmphatics. 

5. In anfractuous wounds, fill up the anf ractuosities with lint, 
so as to avoid the accumulation of fluids. 

6. Preserve the limb as immovable as possible, and avoid 
too frequent dressings. 

7. Abstain absolutely from the application of pure water on 
the wound; always use alcohol. 

8. Whenever there is reason to fear purulent absorption, give 
ergotine in the dose of two to three grammes from the first day, 
and continue as long as the danger lasts, usually ten or twelve 
days. 

A distinguished professor from Rome, M. Mazzoni, pointed 
out the necessity of isolating the surgical wards from those con- 
taining fever or tuberculous patients, a precaution hardly ever 
adopted in French hospitals ; but at Naples, Professor Palasciano 
did not hesitate to tender his resignation when the attempt was 
made to approach a fever ward near that of his operated patients. 
M. Mazzoni asserted the comparative immunity of the Italian 
hospitals, even the maternities, from erysipelas and puerperal 
fever, in all cases except where the usual precautions to exclude 
patients affected with fevers or other contagious diseases, or with 
tuberculosis, are for some reason neglected. 

Mr. Meric, of London, also claimed for the English hospitals 
the merit of great attention to this point, and ascribed to it much 
of the superior success of English surgeons in ovariotomy. 

But sometimes the most lively debates of the entire Congress 
were excited by the question of syphilis, and its means of preven- 
tion by legal measures. With the exception of Dr. Drysdale of 



46 Mary Putnam Jacobi 

London, and one other physician who wished to oppose moral 
education to the extension of the frightful evil, it was everywhere 
assumed that the only efficacious measures consisted in strict 
surveillance over prostitutes. In proof of the results obtained 
by this means, several members read elaborate memoirs. The 
first was sent by M. Wleminckx of Brussels, who pronounces 
that to be the best regulated of cities in this respect. All the 
registered public women are examined every three days, and 
punished if they fail to present themselves for examination. 
Upon the slightest suspicion of disease they are sent to the 
hospital. All physicians are forbidden to treat prostitutes at 
their houses. Rewards are offered to such women as present 
themselves regularly for examination. By means of these 
precautions, M. Wleminckx asserts that the number of syphilitic 
diseases has very considerably abated, and secondary and terti- 
ary affections have nearly disappeared. 

In addition to these measures applied to women, in military 
hospitals all syphilitic patients are rewarded if they will denounce 
the person from whom they have contracted the disease. 

M. Crocq, also from Belgium, observed that these measures, 
so efficacious in the great cities, were neglected in small villages, 
which served as places of refuge for clandestine prostitution, and 
were indestructible foci of syphilis. 

M. Rollet, in the name of the Imperial Society of Medicine 
at Lyons, advocated not only surveillance of the women, but of 
all men in situations where their conduct could be controlled, as 
soldiers, sailors, etc. In view especially of the terrible accidents 
recently occurring at a large glass factory, where the workmen 
being compelled to apply their mouths successively to the same 
tube, nearly all contracted the disease from one whose mouth was 
the seat of syphilitic ulceration, M. Rollet recommends the 
extension of this surveillance to the glass-blowers also. 

M. Buchon made a report of the measures actually enforced 
in the French navy. Every sailor or soldier is submitted to an 
examination, previously to the arrival of the vessel in port, and 
none are permitted to go on shore without a certificate of perfect 
health. Same precautions before leaves of absence are granted. 
Thanks to this incessant surveillance, which although of ancient 
date has been especially vigorous since 1830, the navy department 
has greatly diminished the number of syphilitic patients admitted 



Letters to the Medical Record 47 

into the hospitals. At Brest, where the hospital formerly always 
contained three hundred beds of such patients, the number has 
diminished to one hundred. 

M. Le Fort presented some statistics concerning the actual 
state of prostitution in Paris. The total number of registered 
prostitutes is 3,851, of which 1,306 are distributed among one 
hundred and sixty-five houses — the rest are isolaterl. The 
amount of clandestine prostitution is enormous, but cannot be 
estimated. All soldiers treated for the disease are compelled to 
reveal its source, and the police pursue the woman. A certain 
number of girls are arrested every day for clandestine prostitu- 
tion; among 13,818 of this category, 3,728 were found to be dis- 
eased, 1,131 were sent to St. Lazare, 7,217 reclaimed as minors by 
their families (!), 1,549 or^Y were registered. 

In six years 504,000 examinations have been made with the 
speculum upon prostitutes, and 3,720 contagious diseases have 
been thus discovered. This number is small in comparison to 
the number of examinations, but considerable in proportion to the 
number of prostitutes registered. 

In spite of all this surveillance, as Mr. Drysdale of London 
remarked, syphilis is not less frequent in Paris than London, 
where prostitution receives no sanction from authoritative sur- 
veillance. 

The question that really excited the Congress almost to a 
flame, was that of the possibility of preventing syphilis by inocu- 
lation. It is unnecessary to record the debate in which M. Ricord 
quite overbore M. Auzias-Turenne, who enthusiastically advo- 
cated such inoculation. Several very disastrous and even fatal 
diseases were reported by those who adhered to Ricord's doctrine, 
as the consequence of inoculation with the hard chancre. The 
discussion had no especial result. 

Complementary sessions were held from time to time in the 
evening, in which various interesting subjects were suggested or 
debated. I have already over-passed my space, but must men- 
tion two communications of real curiosity. 

The first is the exposition, by M. Brunetti, of a new method 
for preserving anatomical pieces. His preparations have been 
on exhibition at the Exposition, but the process hitherto has 
been kept secret. In an evening session, however, M. Brunetti 
revealed it; and, as I know from personal examination of his 



48 Mary Putnam Jacobi 

preparation^, the results are so admirable, that every one should 
be acquainted with the method. 

Several operations are included; the washing of the piece 
freeing it from fat, its tanning and desiccation. 

To wash the piece, M. Brunetti passes a current of pure water 
through the blood-vessels and excreting canals; then alcohol to 
expel the water. 

Then ether is made to replace the alcohol in order to dissolve 
the fat; this process requires several hours. The ether penetrates 
everywhere, and everjrwhere accomplishes its work thoroughly. 
At this point, the piece plunged in ether can be preserved in- 
definitely before proceeding to further operations. 

Then tannin is dissolved in boiling distilled water, and this 
solution is passed into the blood-vessels, etc., after the ether has 
been driven out by a current of distilled water. 

Then the piece is dried by being placed in a vase with a 
double bottom, and containing between the two, boiling water. 
By means of a reservoir where the air is compressed to about two 
atmospheres, and which communicates by a stopcock and a sys- 
tem of tubes, first with a vessel containing chloride of lime, then 
with another empty and heated, then with the vessels and ex- 
creting canals of the piece, M. Brunetti establishes a gaseous 
current which expels all the liquids. The operation is then 
finished, and the piece remains supple, light, with its natural 
size and relations, and all its solid histological elements. The 
most perfect microscopic slices may be made from the 
preparation. 

The other invention, which is too good, or at least too strik- 
ing, to be passed by in silence, is an instrument for Somatoscopy. 
This was presented by M. Millot, of Russia, and is designed to 
illuminate the cavities of the body, so as to render them trans- 
parent to the eye. The apparatus is composed of a glass tube 
containing a platinum wire curled up on itself, and communicat- 
ing by copper stems with the two poles of an electric battery. 
When the current is passed, the platinum wire grows glowing 
white, and emits an intense light. This tube introduced into the 
stomach, vagina, or rectum of the cadaver, has enabled the 
observer to see by transparence the walls of the abdomen. M. 
Millot made some experiments upon animals before the Congress, 
but so far he has had no opportunity to test his apparatus on the 



Letters to the Medical Record 49 

living subject. He hopes, however, by its means to bring great 
assistance to the diagnosis of tumors of the ovary, and even 
adherences, and also of calculi and tumors of the bladder. 

P. C. M. 

To the Editor of the Medical Record. 

Sir — To-day celebrates the closure of the Exposition; to- 
morrow will witness the reopening of the Ecole de Medecine, and 
the beginning of the long medical year. 

In Paris, the ceremonies of the year are reserved for its close 
as in Italy, while in England, as in Spain and Portugal, whatever 
solemnities are deemed fitting to dignify the old critical days of 
the scholastic season are observed at the moment of its recom- 
mencement. L' Union Medicate, of Paris, in reviewing the cele- 
brations held at the different schools, greatly commends the 
simpHcity of the English, who quietly assemble at the numerous 
"head-centres" of instruction, listen to a regulation address, and 
immediately set to work at their studies ; whereas, in Madrid and 
Lisbon the affair is made a state occasion, honored by the presence 
of the king and highest public functionaries. It is pomp versus 
utility, says Dr. Simplice, and the contrast is manifest even in the 
themes chosen by the professors for the address. That of Mr. 
Graily Hewitt, for example, at the University College in London, 
was entitled, "The Therapeutic Utility of Alimentation," while 
the discourse of Professor Alonzo at Madrid was devoted to an 
elaborate exposition of "The Benefits of Instruction." 

In Italy, the illustrious Professor Tommasi celebrated the 
close of the year of official instruction by a retrospective review of 
the most important clinical facts that have presented themselves 
to his observation since its commencement. M. Tommasi 
energetically insists on the sufficiency of clinical study to meet 
its own legitimate ends, and protests against the prevailing tend- 
ency to accept the ideas of Chomel and degrade it into a simple 
stepping-stone for pathological anatomy. 

"Clinical study alone has established the causal relations between articular 
rhetunatism and endocarditis, between alcoholism and arthritis on one side, 
and endo-arteritis on the other, between different species of constitutional 
infection and an increase in the volume of the spleen, between syphilis and 
certain special neoplasias of the connective tissue, between scarlatina and 
croupal inflammation of the pharynx and kidneys." 



50 Mary Putnam Jacob! 

You remember that Continental physicians (not including, 
however, the French) are agreed to denominate all inflammations 
attended with fibrinous exudation croupal. 

Epilepsy Depending upon Premature Ossification of the Cranial 
Sutures. 

Among other interesting facts quoted from his clinic, Tom- 
masi signalizes a case of epilepsy in a child, dependant upon 
premature ossification of the cranial sutures, especially the 
spino-occipital. This cause of epilepsy has been specially signal- 
ized by Virchow. In Tommasi's case, the disease was greatly 
ameliorated by the use of nitrate of silver, but it is difficult to 
imagine why. 

Concerning Ptisans. 

The use of ptisans is so widely spread in France, where cold- 
water drinking is considered at once an imbecility and a crime, 
that their selection becomes a matter of considerable importance. 
M. Miquel (de Tours) has just published some suggestions on the 
drinks most suitable in typhoid fever that might be not altogether 
useless at home. He proscribes all amylaceous and sugared 
mucilaginous drinks, especially those containing vegetable acids, 
and all fermentable preparations, on the ground that they in- 
crease the secretion of bile, and the confluence of the intestinal 
eruption. Therefore, instead of lemonade, currant jelly, gum 
and barley water, M. Maquel recommends infusions of linden and 
orange leaves, chamomile and mignonette; also water flavored 
with a few drops of coffee, tea, brandy, or rum. In preparing 
rice water, mixed with decoctions of poppy heads, the physician 
of Tours directs that the rice be not added to the decoction ready 
made, but only allowed to remain in contact with it long enough 
for the water to extract the astringent principle of its rind. 

Dyspepsia and Its Treatment. 

M. Malherbe, of Nantes, publishes some reflections on a 
subject calculated to interest the inmost heart of every American 
— on the treatment, namely, of dyspepsia. Considering that, in 
our favored land, all the blessings of liberty are impotent to save 
us from the grasp of this foul fiend, and that nearly every one 
of us has either had dyspepsia, or actually suffers from it. or is 



Letters to the Medical Record 51 

destined to suffer in the future; no suggestions on the subject can 
afford to be lost. M. Malherbe strongly recommends the use 
of pure hydrochloric acid in all cases of the atonic form of the dis- 
ease. He considers this substance to act as a stimulating tonic, 
which facilitates stomachal digestion by assisting to dissolve 
albuminous substances; by regulating the secretion of gastric 
juice; by remedying constipation in virtue of an exciting action 
on the intestine; finally, by a tonic action on the general economy. 
In various cachexias, even advanced tuberculosis, this medicine is 
found to render good service. I have myself had an opportunity 
of testing the truth of this observation, especially at Laribois- 
siere, in the wards of M. Herard. He is enabled, by means of 
this acid, to greatly relieve the various dyspeptic symptoms 
(among which frequent vomiting is not the least painful) which 
torment the last days of his numerous consumptive patients. 

It is recommended to associate wine of quinquina, calumba, 
or rhubarb, and some preparation of opium with the hydro- 
chloric acid. The following is the formula employed at the Hotel 
Dieu of Nantes: 

Wine of Quinquina lOO grms. 

Syrup Thebaic 30 " 

Pure Hydrochlor. Acid i " 

Mix. 

The dose is from two to six teaspoonfuls a day. To relieve 
the gastralgic pain to which many dyspeptics are martyrs, 
M. Miquel suggests the administration of a concentrated opiate 
combined with a bitter, which serves to correct its injurious 
effects. The following is his formula: 

Syrup of Bitter Orange Peel, ") 

" Morphine >■ aa q.s. 

Ether J 

Mix. 

Where the pain comes on principally before eating, it is 
advisable to administer a narcotic or etherized draught about a 
quarter of an hour before meals. It is M. Herard's practice to 
give his patients ten drops of Sydenham laudanum immediately 
before, and one grm. of pepsine immediately after eating. This 
treatment entirely relieved the pain, and stopped the vomiting in 



52 Mary Putnam Jacobi 

the case of a woman, who subsequently died from the effects of a 
diarrhoea maintained by deep tuberculous ulcerations of the 
intestines, and with whom the mucous membrane of the stomach 
presented the signs of such an intense arborescent injection, 
mingled with yellow and slate-colored spots, as really merited 
the title of gastritis. 

Arsenic in Cerebral Congestions. 

Therapeutics does not constitute atpresent the most fashion- 
able subject of meditation in the medical world, so much the 
more, therefore, do I glean studiously all indications of experi- 
ment in this direction. M. Lisle had just read a note before the 
Academy on the advantages of arsenic in the treatment of inter- 
current cerebral congestion among the insane. M. Lisle con- 
siders hallucinations to be, not a symptom, but a complication of 
insanity, and always dependent upon congestion, consequently 
always to be treated by arsenious acid. He claims to have cured 
131 patients out of 193 by the use of this medicament, and to 
have markedly ameliorated the condition of twenty-nine others. 
If the facts cited by M. Lisle are trustworthy (and there is no 
reason to suppose they are not) they are in striking opposition 
with his theory. According to the analogy of its action in all 
other cases, arsenious acid should be considered as an eminent 
tonic of nutrition, regulating the life of the capillaries, perhaps, in 
several ways, but by no means tending to disgorge them of un- 
seemly congestion. At the hospital Beaujon, M. Montard 
Martin told me that he employed arsenious acid with consider- 
able success against cholera in the last epidemic, and there 
seemed reason to suppose that the capillary circulation of the 
surface was restored or stimulated by this potent drug in a 
manner to relieve the deadly visceral congestion. Moreover, as 
the editor of the Montpellier Medical remarks, it is far from 
proved that hallucinations are connected with congestion of the 
brain, a condition not indicated merely by some redness of the 
face and brilliancy of the eyes. According to the ideas of Luys 
in his recent brilliant researches into the minute anatomy of the 
cerebro-spinal system, hallucinations occur when the thalami 
optici instead of simply receiving impressions from without and 
irridating them to the periphery, set up an independent action, 
and originate impressions in the recesses of their own structure. 



Letters to the Medical Record 53 

This might occur whether they were excited by congestion or 
their normal functions perturbed by anaemia. 

For those who have not read M. Luys' book, it may be 
necessary to explain that many of his views on the structure 
of the brain are quite original. The particular theory to which 
I have just referred rests on another, purely anatomic, namely, 
that all sensitive fibres proceeding from the posterior and lateral 
columns of the spinal cord, are destined to terminate in the thai- 
ami optici, which constitutes the first receptacle and halting 
place for impressions received from the world without. Here 
the crude impressions are elaborated and ultimately radiated to 
the vesicular matter of the convolutions along the converging white 
fibres that apparently proceed from the surface to the base of the 
brain. These are not, as generally affirmed, the mere continu- 
ation of the fibres from the cord, but new ones, deriving their 
origin from the thalami optici themselves. 

The Characters of Cerebral Softening. 

In this connection it is natural to mention the essay in the 
Archives de Medicine, written by Proust, on softening of the 
brain. The dominant idea resulting from the researches of this 
distinguished young physician, is the separation of softening 
{ramoUissement) both from encephalitis and haemorrhage. 
Encephalitis determines a neoplasia, or is equivalent to it, 
precisely as inflammation generally involves the idea of exudation. 

Heemorrhage usually results from the rupture of a capillary 
aneurism. But ramoUissement is a necrobiosis, essentially the 
same as gangrene of the limbs, and its phenomena only differ 
because the tissues involved are withdrawn from the action of 
the air. M. Proust, however, reserves the name necrobiosis 
for a molecular destruction of tissue, and to its destruction en 
masse assigns the term necrosis. 

The death of the cerebral substance depends upon obstruc- 
tion of the capillary circulation, however caused, whether by a 
thrombus, an embolus, stricture of the cerebral arteries, fatty 
degeneration of the capillaries, thrombus and phlebitis of the 
sinus, etc. In these cases, there may be produced either a condi- 
tion of aneemia or of hyperaemia. If an obstacle to the circu- 
lation be situated in the sinus, there is always hypereemia; 
obstacle in the capillaries occasions rather anaemia. The first pro- 



54 Mary Putnam Jacobi 

duces the red, the second the white softening. Hyperaemia of the 
parts surrounding the focus of softening is easily explained by the 
collateral fluxion in branches of the vessel whose tension has 
been increased by the obstacle to the circulation. Hyperaemia 
of the centre of the infarctus is more difficult to account for, and 
M. Proust only suggests with some hesitation, that it may be 
due to some action on the part of the vaso-motor nerves, or the 
result of a functional alteration of the capillaries. 

The white coloration is rarely observed, but occurs occasion- 
ally in cases of general cachexia, as in the case of cancerous 
patients. 

The red coloration may be uniform, and is then more marked 
at the periphery; or spotted, and then results from little haemor- 
rhages arising from the rupture of a great number of capillaries. 

Diminution of the consistence of the part is appreciable from 
the second day. The tissue has a trembling jelly-form appear- 
ance. Then the part becomes tumefied, it is softer, the furrows 
separating, the convolutions disappear, and by the third or fourth 
day it has become reduced to a diffluent paste. 

The first phenomenon detected by the microscope is the 
appearance of fatty granulations in filtering the tissue. These 
have been observed at the end of twenty-two hours by Charcot, 
and thirty-six hours by Prevost and Cotard. Then granular 
bodies succeed to these fatty granulations and accompany them. 
According to Bouchard these granular bodies consist of agglomer- 
ations of fatty granulations. 

Transformations speedily take place, corresponding to what 
has been described under the name of chronic softening, plaques 
jaunes, cellular infiltration. The coloring matter of the blood 
transudes through the walls of the capillaries; that already cxtra- 
vasated becomes converted into yellow granular amorphous 
masses, or else into reddish oblique rhomboidal crystals, the 
hasmatoidine of Virchow. 

Later, a neoplastic effort sets up, and a tendency to cicatri- 
zation appears; the pia mater contracts adhesions with the 
bottom of the excavation that has been formed by resorption 
of disorganized tissue, and across this excavation are extended 
laminae of connective tissue. The tissue surrounding the soft- 
ened part becomes slightly indurated in virtue of a proliferation 
of nuclei and cells. This last is analogous to the formation 



Letters to the Medical Record 55 

of an eliminating membrane around a patch of gangrene in a 
limb. 

Prdvost and Cotard, under the direction of Vulpian, have 
made a number of experiments on the production of foci of 
ramollissement by injection into the arteries of powder of lycopo- 
dium or tobacco. They succeeded in simultaneously provoking 
infarctus in the brain, the spleen, and the kidneys, were able to 
observe the apparition of fatty granulations and granular bodies, 
and determine the formation of plagues jaunes. 

Although the opinions have been refuted which attached 
softening to inflammation, on account of a mistaken idea that the 
yellow degeneration consisted of pus, Proust admits that certain 
analogies exist between the two affections, especially in the 
formation of the zone of proliferation. Further, that it is im- 
possible to say that heemorrhage and softening exercise no mutual 
influence on each other; on the contrary, the first tends to destroy 
the tissue directly, and to cut off its nutrition, or, on the other hand, 
the second, by withdrawing from the capillary walls their normal 
support, predisposes them to yield to the pressure of the blood. 

The influence of atheroma upon the production of haemorrhage 
is of course unquestionable. I had an opportunity of observing 
a remarkable illustration in an autopsy recently performed at La 
Charite. The aorta was atheromatous from its base to a point 
below the cross; the carotids were sprinkled with atheromatous 
patches, but arrived at the brain, the internal carotid showed 
complete degeneration. The same was true of the branches 
of the basilar artery. In this brain, sections in any direction 
revealed a punctuated injection caused by rupture of the capil- 
laries, and in the middle lobe of each side, adjoining the thalami 
optici, existed a small focus of haemorrhage. 
Truly yours, 



P. C. M. 



Paris, Nov. 3, 1867. 



Curious Nervous Phenomena. 



To the Editor of the Medical Record. 

Sir — The "sensation" of the week centres around the 
discussion of a remarkable circumstance occurring in the wards 
of M. Richet at Hotel Dieu. On the 23d of October, a woman 



56 Mary Putnam Jacobi 

entered the service, who, falling against some pieces of sheet 
copper, had been wounded in the forearm by their sharp edge, in 
such a manner that the radial artery and median nerve had been 
completely divided. Notwithstanding this section, sensibility 
remained in the thumb, index and middle fingers, and the exter- 
nal border of the ring finger, all furnished by the median nerve; 
moreover, the peripheric extremity of this nerve was exquisitely 
sensitive to the touch of the pincers. 

The fact has been examined and acknowledged by a number 
of distinguished physicians. There can be no doubt that the 
median was completely severed. But it is difficult to explain a 
phenomenon so contrary to the facts which form the basis of 
current physiological theories, according to which the peripheric 
extremity of a severed motor nerve preserves its motor power, and 
that of a sensitive nerve loses its sensibility. Dr. Fort, in the 
Union Medicale, endeavors to prove that the case is one of recur- 
rent sensibility, like that described by Bernard as existing in the 
facial nerve. Irritation of this nerve excites pain, on account of 
its anastomoses with the trigeminus. In the same way, says 
Dr. Fort, we must infer from this fact itself that the radial and 
cubital nerves furnish anastomoses with the median, by which 
this latter is enabled to preserve its sensibility even after section. 

This argument is rather post factum. Moreover, as ob- 
served by Dr. Reveillant in the Gazette des Hopitaux, there is no 
analogy between the coupling of a sensitive and motor nerve in a 
single "nervous pair" (as in the case of the 5th and the 7th) and 
this supposed anastomosis between two sensitive nerves, which 
is justified by no precedent whatever. Dr. Reveillant maintains, 
that since the grand palmar nerve is more deeply situated than 
the median at the wrist on the level of the wound, since it is 
united to the median only by a loose cellular tissue which permits 
great mobility, since the median was torn, instead of being dis- 
tinctly cut, and the wound was deepest on the radial border of 
the wrist — in view of these considerations it is probable that the 
great palmar nerve was not divided, as at first supposed, and the 
recurrent sensibility was due to its presence in the parts furnished 
by the median. But this explanation, though hypothetically 
satisfactory for the sensibility remaining in the hand, renders 
no account of that preserved in the peripheric extremity of the 
median, since the palmar branch is given off from this latter 



Letters to the Medical Record 57 

nerve at a point above the situation of the wound, and after- 
ward has no connection with the median. Dr. Richet has not yet 
spoken. His detailed description of the case is presently ex- 
pected, and may throw light on this vexed question. 

Experiments upon Criminals. 

At the naval medical school of Brest, M. le professeur Duval 
has pursued some physiological researches in a direction that 
continually tends to become restricted. If the humanitarian 
tendencies of the age prevail, capital punishment will be abolished 
and physiologists for ever deprived of the bodies of criminals as 
material for experiments. In view of this unfortunate con- 
tingency, all experiments actually performed are invested with a 
double interest, on account of the possibility that they may be 
the last permitted in civilized countries. 

The following is a resume of the results obtained by M. 
Duval, in galvanization of the different apparatus of the bodies of 
criminals, within five or six minutes after their execution. 

Nervous System. — Galvanization of the motor ocular nerve, 
at its point of immersion in the cavernous sinus, caused instant 
contraction of the dilated pupil. In two subjects reflex move- 
ments were excited by a brusque tap on the hands or feet. The 
contractions of the deltoid, brachial, biceps, anterior tibial and 
gastro-nervous muscles were especially evident. In the case of 
a slight irritation of the surface, exciting contraction of the sub- 
jacent muscles, the action was evidently reflex: where a smart 
percussion had been practised, M. Duval supposes that the 
muscular fibre had been directly excited, independent of the 
nerves. This experiment confirms Schiff's refutation of the 
theory that warm-blooded animals could not exhibit reflex 
movements after decapitation. 

Digestive Apparatus. — The stomach and small intestines 
continued to exhibit peristaltic movements for several minutes. 
The stomach was filled with food, and in the midst of digestion, 
but none of its contents escaped at the orifices after removal of 
the organ from the abdomen, so efficient was the contraction of 
the sphincters. A remarkable prominence of the solitary closed 
follicles of the ilium was observed. This fact is interesting, on 
account of a theory recently proposed, which considers such 
prominence to be a characteristic lesion of cholera. 



58 Mary Putnam Jacobi 

Circulatory Apparatus. — The primitive carotids were divided, 
and their extremities were seen to rise at regular intervals, elon- 
gate beyond the level of the wound, and then subside; at each 
impulse a small quantity of frothy vermilion blood escaped. 

On the same two subjects, the thorax was opened seven 
minutes after death, and the heart found to be beating within 
the pericardium. Upon incision of this membrane, the following 
succession of phenomena was observed. At the beginning of 
each movement the auricular appendix was suddenly raised, and 
distanced from the aorta, then fell as abruptly into its primitive 
position. In rising, the appendix lengthened, and the indentures 
of the circumferences parated like the fingers of an outstretched 
hand. At the same time with this erection of the appendix, 
occurred an expansion of the auricle, as if it were distended by an 
efflux of liquid. The contraction of the ventricles followed 
that of the auricles in less than the fifth of a second. These 
cavities were shortened in all their diameters, their surface 
became furrowed, they contracted together in perfect 
S3nichronism. 

After cessation of the spontaneous beatings of the heart, 
the movements were renewed by the application of galvanism, 
first to the organ itself, afterward to the spinal cord. 

M. Duval found that a moderate degree of contractility 
existed in the walls of the aorta, which, irritated by the insertion 
of a finger, were found to slightly press upon it. 

Respiratory Apparatus. — Upon galvanization of the external 
or internal intercostal muscles, or of both together, the under rib 
was raised and pushed outward. M. Duval concludes that both 
these muscles, concerning which, from the time of Haller and 
Hamberger, there has been so much discussion, are inspiratory. 
M. Duchenne (de Boulogne) impresses this fact into his service 
to prove the same theory. 

Atrophy of Muscles of Trunk and Limbs. 

I am not sure whether I have mentioned the lecture delivered 
by Duchenne upon a patient in the wards of M. Bouillaud, 
affected with atrophy of nearly all the external muscles of the 
trunk and limbs. The intercostal muscles were entirely wasted, 
and the chest is flattened in a remarkable manner. The 
respiration is performed by the diaphragm. M. Duchenne 



Letters to the Medical Record 59 

remarked, that since the thorax contracted, as in expiration, as 
soon as the intercostal muscles became powerless, it was just 
to infer that in health they antagonized this contraction; that 
is, opposed the action of the expiratory muscles. It seems to me 
evident, however, that the case in question proved that they 
exerted such antagonism in virtue of their tonicity, not at all on 
account of the intermittent contraction during inspiration. The 
experiments of M. Duval are no more conclusive, for although a 
muscular fibre when galvanized should elevate a rib to which its 
fibres were attached, we are not thence to infer that it contracts 
habitually during life, or therefore that it directly elevates the 

ribs during inspiration. 

P. C. M. 

To the Editor of the Medical Record. 

Sir — Before the Academy of Sciences, M. Sappey presented 
a note announcing the existence of nervi nervorum, or nervous 
filaments, in the neurilemma of nerves, analogous to the vascular 
ramifications in the coats of blood-vessels. The distinguished 
anatomist has followed these filaments as far as the sheaths 
enveloping the secondary trunks of nerves, but they are never 
found in the envelope of primitive fascicules. The internal 
envelope of the optic nerve receives no nervous filament. The 
external, on the contrary, receives a number from the ciliary 
nerves. This external sheath is also remarkable for the abund- 
ance of elastic fibres which enter into its composition. It 
therefore differs notably from both the sclerotic and the dura 
mater, which are deficient both in nervous filaments and elastic 
fibres. 

The Curvature of the Spine and the Ossification of the Ribs. 

M. Sappey is the Chef des Travaux Anatomiques, and has 
just reopened his popular course at the Ecole Pratique. At a 
lecture at which I had the pleasure of "assisting" the other day, 
M. Sappey referred to two points which had been the object of 
some recent personal researches, and may not, therefore, be well 
known to you. One was an explanation of the curvatures of the 
vertebral column by the obliquity, in the cervical region of the 
intervertebral disks, in the dorsal, of the bodies of the vertebrae, 
and in the lumbar, of both bodies and disks. Hirschfeld had 



6o Mary Putnam Jacobi 

attributed these curvatures to the action of the yellow ligament, 
and declared that they were destroyed by its section. M. 
Sappey had repeated the experiment, and found this assertion 
incorrect — the curvatures persisting. 

The other point referred to was the ossification of the ribs. 
According to M. Sappey, the ribs, like the bones of the craniiun 
and the face, pass through no cartilaginous stage, but a thread of 
osseous substance is found to be formed directly in the midst of 
the original "mucous" mass. 

The Function of the Vaso-Motor Nerves. 

Drs. Eulenbers and Landois have published a series of articles 
upon the function of the vaso motor nerves, and upon the r61e 
they seem to play in a certain intermittent ophthalmia. Grie- 
singer considers this affection to be a form of latent intermittent 
fever, as a neuralgia of the eye more or less severe, accom- 
panied by congestion more or less intense. It is nearly always 
unilateral, and consists in an intense hyperasmia of the eye, 
with photophobia, suffusion, contraction of the pupil, and often 
oedema of the iris. When the disease is of long standing, it may 
terminate in chronic ophthalmia, or in atrophy of the bulb. 
Griesinger considered the presence of neuralgia essential to 
characterize this form of ophthalmia, but Mannhardt has 
reported a case where this symptom was entirely wanting. 

A man thirty-six years old was suddenly attacked at nine 
o'clock in the morning with an acute catarrhal conjunctivitis. 
Intense redness and swelling of the palpebral and bulbar con- 
junctiva, abundant flow of tears mixed with mucous flocculi. A 
collyrium of acetate of lead was ordered. The next morning 
there was no trace of the affection but it returned with as much 
intensity as ever at two o'clock in the afternoon. The same 
collyrium was employed, and the inflammation again disappeared, 
to reappear the fifth day between nine and two o'clock. Small 
doses of quinine were then ordered. An access of moderate 
intensity occurred the seventh day, but from the ninth the dis- 
ease did not return. 

It may therefore be admitted that the vaso-motor filaments 
of the trigeminus may be affected independently of the sensitive 
fibres and that intermittent ophthalmia may exist uncompli- 
cated by neuralgia. 



Letters to the Medical Record 6i 

Curious Phenomena Presented by Primitive Syphilitic Indiu"a- 
tions. 

In the Archives of Medicine for November, M. Foumier, a 
distinguished agrege of the faculty, has called attention to certain 
curious phenomena occasionally presented by primitive syphilitic 
indurations. The first and most interesting is an ulceration of 
the cicatrized chancre. The second is the softening of the cen- 
tral and deep portions of the induration, and its progressive 
elimination in the form of a purulent detritus. The third pheno- 
menon relates to the production of secondary indurations, result- 
ing from the primitive affection, and occurring in the neighbor- 
hood of the initial chancre. 

In the first case, the physician may have had to deal with a 
chancre which has accomplished its different phases with perfect 
regularity, and has cicatrized in a perfectly satisfactory and 
apparently definite manner. Under certain circumstances (of 
which an unusual abundance of the induration seems the most 
characteristic) this cicatrix is found to open, ulcerate, and erode 
in various points; — a new wound is thus formed on the surface 
of the induration, which sometimes excavates its entire extent. 
M. Foumier has observed this secondary ulceration to be repeated 
three times on the same base. In the cases in question the 
rupture of the chancre is entirely spontaneous. 

Although in the greater number of cases the ulceration takes 
place on chancres in which the induration is excessive, it may 
also occur when this is of only medium intensity. The ulcer is 
formed from the eighth and fifteenth days after the cicatrization. 
Sometimes it is quite superficial, a simple erosion; sometimes it 
affects the excavated form. A sanguinolent rather than puru- 
lent liquid is secreted by the wound. The ulcer generally heals 
with remarkable rapidity, and, although sometimes alarming 
from its extensive and ragged aspect, it is in reality benign. 
Even when assuming a phagedenic form, it readily heals with 
only an application of dry lint. 

The conversion of the cicatrized chancre into an abscess, 
much more rarely occurs than its ulceration. In this case, also, 
the cicatrix has been regularly formed, and the induration is 
generally excessive. Presently the centre of the mass is felt to be 
softened, and a little later a small opening is discovered, through 
which is eliminated a yellowish sanguinolent liquid, puriform 



62 Mary Putnam Jacobi 

rather than purulent. As many as six openings have been 
observed, each leading by a curiously formed little passage into a 
central focus of softening. The integrity of the outer layers of 
the mass is preserved. 

It is evident that the ulcer and the abscess are really analogous 
lesions, each producing a liquefaction and consecutive elimin- 
ation of the pathological tissue of the induration. May not the 
exaggeration of this latter, which has been found so generally 
to coincide with the lesions, be indirectly their cause, on accoimt 
of opposing greater difficulty to the ordinary process of absorption ? 

The secondary indurations may ulcerate, and assume the 
aspect of primitive hard chancres. M. Foumier thinks that it is 
on account of cases of this kind that Babington had been led to 
maintain that syphilitic induration preceded ulceration. An 
opinion that M. Foumier has no hesitation in pronouncing 
erroneous, if only on account of the difficulty of diagnosis between 
initial chancre and herpes. 

Operations for Naso-Pharyngeal Polypus. 

The Gazette des Hopitaux contains an account of an interesting 
operation practised at the Hotel Dieu of Clermont Ferrand, for a 
naso-pharyngeal polypus. The patient was a boy of eighteen, 
extremely diminutive and fragile. The polypus had apparently 
existed eighteen months. The right cheek was but slightly 
deformed, but the difficulty of speaking, and the embarrassment 
of the respiration, forcing the patient to keep the mouth partially 
open, indicated the existence of a material obstacle to the 
entrance of air. 

The soft palate was pushed forward by a hard, resistant, 
bright-red tumor, whose lower border projected below the uvula, 
its adherent edge mounted in the pharynx. The nostril of the same 
side was obstructed by a fleshy mass, evidently only an expansion 
of the guttural tumor. 

The finger, introduced between the cheek and the alveolar 
arcade of the upper maxilla, distinguished a small tubercle 
which corresponded to the exterior tumor. The point of insertion 
was difficult to determine; nevertheless it seemed probable that 
the tumor adhered rather to the pharynx than to the nasal fossa. 

After some delays, during which the respiration became 
more and more embarrassed, M. Fleury determined to afford the 



Letters to the Medical Record 63 

patient the only chance for life that remained, by practising 
the resection of a portion of the maxilla, and thus extracting the 
tumor. The patient being under the influence of chloroform, 
an oblique incision was made from the commissure of the lips to 
the external angle of the orbit. Only one artery required 
ligature. The upper flap was dissected to a considerable dis- 
tance, then a chain saw introduced by means of a curved needle 
into the spheno-maxillary cleft, to separate the maxilla from the 
malar bone. The second lateral incisor tooth was extracted, and 
the cisailles, introduced into the mouth and right nostril, easily 
divided the palatine vault — a section practised with scissors 
separated the apophysis of the maxilla ; it then was only necessary 
to apply the blade of the same instrument underneath the orbit 
and exercise a light pressure, to loosen the bone. The soft parts 
uniting it to the subjacent tissues were detached with curved 
scissors, and the bone then easily removed. The nasal fossa and 
zygomatic cavity were thus laid open, and the opening, though 
smaller than if the maxilla had been entirely removed, was 
sufficiently large to give passage to the tumor, and the risk of 
deformity was much less than would have been incurred by the 
other operation. The polypus being discovered, was much 
larger than had been supposed, since it occupied the cavities 
of the face. As much as practicable, M. Fleury endeavored to 
enucleate the tumor. The pedicle was implanted by a large and 
resistant base in the upper part of the pharynx. It was for- 
tunately but slightly vascular, and the slight hsemorrhage 
following its division was easily arrested by the cautery. The 
tumor weighed 112 grains, and was nearly entirely flbrous. 

The second day after the operation, inflammation of consider- 
able intensity set up around the wound, and destroyed all hope of 
union by first intention. The following days a suspicious odor 
escaped from the mouth and nostrils, which was partially neu- 
tralized by lotions of chlorinated soda. The patient was ex- 
tremely feeble, and a fatal termination was dreaded. How- 
ever, after some days of uncertainty, the lips of the wound, 
which had opened, assumed a better appearance and became 
covered with healthy granulations, the patient was able to 
rise, to eat, and from that moment the convalescence was 
assured. 

The inflammation was attributed in part to the use of the 



64 Mary Putnam Jacobi 

actual cautery. The wound was dressed with lint steeped in 
camphorated alcohol. 

This is the third case in which M. Fleury has saved a patient 
from inevitable death, by boldly venturing on this formidable 
operation on the maxilla. 

Among the clinics recommenced with the reopening of the 
year, that of M. Gosselin, who has succeeded the lamented 
Velpeau at La Charite, is not the least interesting. The inaug- 
ural lesson was divided into three parts. In the first the new 
professor paid a just tribute to the memory of his predecessor. 
In the second, he traced a rapid sketch of the history of this 
famous hospital, founded by Marie de' Medici 260 years ago. 
During 150 years there was no clinic, and the names of no surg- 
eons have come down to us. The first illustrious clinician of the 
Charite was Desault, who instituted the concours for the position 
of assistant surgeon. Deschamps was the first who obtained 
this title, and also the first who availed himself in his scientific 
writings of observations taken among his hospital patients. 
Until then, observations had always been collected from the 
writer's private clientele. Of all the writings of Deschamps, the 
best known are his "Observations on the Ligature of the Principal 
Arteries of the Extremities, on Account of Wounds or Aneur- 
isms." Boyer succeeded Deschamps, and Roux followed Boyer; 
finally Velpeau took the place of Roux, when the latter suc- 
ceeded to Dupuytren at Hotel Dieu. 

The third part of the lesson was devoted to two patients in 
the wards, one with a fracture of the wrist, the other with an 
encysted encephaloid tumor at the internal and lower part of the 
thigh. Space does not permit me to quote at length M. Gos- 
selin's remarks, further than that, in the latter case, he con- 
sidered that amputation would not prevent a return of the 
tumor, but would prolong life. 

P. C. M. 

To the Editor of the Medical Record. 

Sir — You will remember, no doubt, that at the International 
Congress the theme which opened the debates, and which 
occupied a most prominent place in the discussions, was the 
apparently exhausted subject of tuberculosis. M. Villemin has 
just offered to the Academy the treatise of which his remarks 



Letters to the Medical Record 65 

at the Congress were the abstract, the exposition, and the 
defence. The researches of this ingenious experimentalist have 
led him to conclusions differing so widely from those generally 
adopted, as to excite the curiosity, applause, or indignation 
of every defender of the medical faith. Hence the report of M. 
Colin on Villemin's book has been followed by an able and lively 
discussion of unexpected interest in connection with a disease 
which had, so to speak, fallen into disuse, and whose victims 
were regarded as useless incumbrances of the clinical wards 
in the hospitals. 

Inoculability of Tubercle. 

The novelty of Villemin's views is manifested on three 
important points, ist. Denying the existence of epithelium 
in the pulmonary alveoli, the physician of Val-de-Grace contra- 
dicts Reinhardt's assurance that the cheesy masses occupy the 
air-cells, and ascribes to them the same origin and seat as that 
generally admitted for the gray granulations, viz. the connective 
tissue between the alveoli, and around the blood-vessels. These 
masses are the result of fatty degeneration of the plasmatic 
elements of the connective tissue, whose proliferation has given 
rise to the nuclei and small cells characteristic of the centre of 
the gray tubercle. These last elements invariably degenerate, 
but not unfrequently the large connective cells on the periphery 
of the granulation are also invaded while yet undergoing the pro- 
cess of multiplication. In this respect therefore, Villemin returns 
squarely to the views of Laennec, who regarded the cheesy 
masses as softened tubercles. 

2d. The most remarkable part of the Etudes sur la Tuberculose 
is that which relates to the experiments on inoculation of tuber- 
culous matter, some of whose results were submitted to the 
Academy in 1865. Villemin was induced to make these experi- 
ments, by observing the histological resemblance of the ele- 
ments of the miliary tubercle with those of the tubercle of 
syphilis or glanders. Since they were specific and inoculable, 
he inferred that the gray granulation might be so as well. The 
second half of this supposition has been fully confirmed. An 
immense number of experiments have been performed upon 
rabbits, by inserting into the subcutaneous cellular tissue frag- 
ments of pulmonary tubercles, and in nearly all cases the injection 



66 Mary Putnam Jacobi 

was followed by an eruption of miliary granulations in the lungs, 
and by the constitutional symptoms of tuberculosis, to which, 
after awhile, the animals succumbed. 

3d. Upon the success of these experiments, the first of any 
consequence that have ever been made in this direction, M. 
Villemin bases an entirely new theory of tuberculosis. He claims 
that what is inoculable must be specific; that tuberculosis 
belongs, in its character of specificity, to a family of diseases, 
depending on the substantial introduction into the system of a 
peculiar animal virus. It is, in short, a definite, virulent, con- 
tagious disease, like syphilis and glanders; and the histological 
similarity between the tumors in the three cases is justified, so to 
speak, by their family or generic affinity. 

Now, as to the reality of the results obtained by M. Villemin 
in his experiments, there can be no doubt. They have been 
repeated with equal success by M. Colin, who reports the new 
treatise to the Academy; their accuracy is acknowledged by M. 
Cornil, from whose party Villemin has made such a frightful 
secession. Bouchard, in his review in the Gazette Hehdomadaire, 
and Chauffard and Pidoux in their speeches at the Academy, all 
admit this striking and unexpected discovery — viz. that tuber- 
culosis, anatomically and clinically characteristic, may be com- 
municated to rabbits and guinea-pigs by inoculation from the 
tubercles of cattle or human beings. 

But the inferences adopted by M. Villemin are extremely con- 
testable and contested, as M. Chauffard by an anatomical, M. 
Pidoux by a general analysis, successfully disproved the pre- 
tended virulence of the tubercular deposit. Chauffard points 
out that inoculations of specific animal poisons, as those of 
syphilis, small-pox, hydrophobia, etc., are first made with fluids 
containing no morphological elements or special characteristics. 
But Villemin's favorite experiments consisted in grafting a definite 
structure upon the organism. When this structure, sown on 
soil rendered congenial by the presence of l>Tnphatics, develops 
itself and excites the surrounding tissues to similar proliferation, 
it does so in virtue of the laws of development of tumors, which, 
according to Virchow, depend on the foundation of a tissue by 
elements coming from another tissue. 

2d. A definite period of incubation is essential to the process 
of virulent inoculation; after which appears local trouble, speedily 



Letters to the Medical Record 67 

followed by general symptoms of infection. But M. Colin shows 
that in the experiments there is no such incubation, and no 
reproduction of the tubercle on the place where it was inocu- 
lated. The tumefaction observed there results from the resist- 
ance offered by the tubercle to the dissolving action of altered pus, 
on account of which some of the matter originally introduced may 
often be found on the same spot six weeks afterwards. M. Pid- 
oux declares that the tubercle, placed at the base of the scale of 
heteroplastic formations, multiplying like all inferior organisms, 
dying speedily, and infecting the locality with products of decom- 
position, is in the highest degree incapable of the incubating 
force, the latent and refractory vitality characteristic of virus. 

3d. The gray granulations are possessed of no exclusive power 
of infection. Villemin himself has produced an eruption of 
miliary tubercles by inoculation of the cheesy detritus, and even 
admits this to be the most favorable for the experiment. It is 
on this fact that he bases the revival of the doctrine of identity 
between the cheesy mass and the crude tubercle. M. Colin has 
successfully inoculated various animals, rabbits, guinea-pigs, 
lambs, calves, and dogs, not only with the cheesy deposit, but 
with the hard cretaceous tubercle from the lungs of oxen. Clarck 
has succeeded with ordinary pus ; and Empis with pus from puer- 
peral peritonitis, from the surface of Peyer's patches ulcerated 
in typhoid fever, and from suppurating fibrinous pneumonia. 
Finally, Lebert has experimented with mineral substances, as 
mercury and carbon. In all these cases a crop of perfectly char- 
acteristic gray, hard, semi-transparent tubercles was obtained in 
the lungs of the animals submitted to the experiment. It is 
impossible to imagine a more complete demonstration of the 
common and non-specific origin of the crude tubercle. 

4th. M. Colin, in his report, follows step by step the conse- 
quences of the inoculations, and shows that for a long time they 
are purely local. The disease is communicated, not by the 
general infection of the whole system, but by the implantation of 
a thorn, whose irritation gradually extends and involves the 
lungs. The focus of inoculation is presently surrounded by 
radiating white lines, formed by lymphatic vessels engorged with 
foreign matters. The ganglia in which these vessels terminate 
engorge themselves also, and become filled with tubercular 
granulations, and others in their turn. The ganglia not found on 



68 Mary Putnam Jacobi 

the route traversed by the morbid vessels, remain perfectly 
sound. From the lymphatic system, the tuberculous matter 
gains the central organs, probably by the route of the circulation, 
and is thus gradually deposited in the lungs, liver, spleen, and 
kidneys. This evolution is exactly that of the gradual propa- 
gation of a local evil, not the simultaneous impregnation of the 
entire organism by a virulent agent. 

Colin is so impressed by this local character of the disease 
artifically produced, that he jumps to the conclusion that natural 
phthisis is also the result of local mischief, resulting from one or 
more tubercles that have at some time been introduced into the 
economy, and after remaining latent for an indefinite period, are 
suddenly awakened to activity. But this supposition is entirely 
gratuitous. 

5th. M. Pidoux dwells upon Villemin's admission that the 
yellow tuberculous matter is more active than the gray tubercle. 
If we assume (which, as we shall presently see, is conceding too 
much) that this cheesy deposit be in fact a degeneration of the 
tubercle, a striking contrast becomes apparent between the 
tubercle and virus. This is more active in its first stages than at 
the period of its degeneration. 

6th. Pidoux also observes that the similarity between the 
histological structure of the tuberculous tumor and of syphilis 
and glanders, is really an argument against the virulent character 
of the first affection. For at the moment that the other two 
diseases have resulted in tumors, they have ceased to be virulent, 
and have passed into a state of diathesis. Inoculation from those 
tumors will give rise to neither glanders nor syphilis. Hence 
this grand foundation-stone of the new theory, and this initial 
observation of M. Villemin's researches, is wrenched from him, 
and turned most ingeniously into a powerful argument against 
his cause. 

From this critique it appears that inoculation of tuberculous or 
other matter acts on the lungs (whither it has been brought by 
the blood, and arrested by the fine network of capillaries), by 
irritation of the plasmatic cells of the connective tissue. These, 
proliferating, give rise to the small elements, which, closely 
crowded together, constitute the gray tubercle. The process is 
closely analogous to the proliferation of inflammation, which 
also results in the formation of the small cells and nuclei of pus, 



Letters to the Medical Record 69 

which cannot by their form be distinguished from those of the 
crude tubercle. The difference consists — first, in the intercellu- 
lar substance, liquid in pus, finely granular in the tubercle; second, 
in that the fatty degeneration results in cheesy masses for the 
tubercle, while the pus remains liquid. 

In all cases of artificially induced disease the irritation comes, 
of course, from without, and may be called local. This may 
occur also, as Pidoux observes, in acquired phthisis, especially in 
that of miners and others constantly exposed to direct irritation 
of the lungs. But in constitutional and hereditary consiimption 
the tubercular process is to be regarded simply as the final stage 
to which all irritative processes in weakly subjects naturally tend 
to degenerate. 

"The impoverishment of the field of nutrition is the first 
condition of tuberculosis," says Pidoux; "the occurrence of some 
irritation the second. Nothing is more susceptible of irritation 
than weakness, nothing so ready to degenerate." Again (for I 
quote willingly from this able and brilliant discourse in which the 
old colleague of Trousseau so well justifies his reputation), 

tuberculosis is the constitutional alteration, the characteristic and organic 
heteroplasia of the lymphatic apparatus, the fundamental apparatus of 
nutrition. This is attacked in the connective tissue, which constitutes its 
base. When this tissue sustains what Hunter calls the stimulus of imperfection, 
it is excited to proliferations, imperfect, sickly, of an extremely ephemeral 
vitality, born in fact but to die; such is the tubercle. 

Chauffard ingeniously suggests that the ease with which the 
tubercle may be inoculated depends precisely upon the poverty 
of its organization. The fecundating tissue, to refer again to 
Virchow's idea and expression, would need to make less effort 
to assimilate another to a feebly organized structure, than to one 
complex, rich, and characteristic; and from this point of view 
the inoculation of tubercle is more easily comprehensible than 
that of cancer. 

But the existence of an internal cause for tuberculosis, 
of a diathesis and of hereditary tendency, is denied by M. Ville- 
min, and it is this denial that constitutes the fame of his heresy. 
He is as frank a believer in the contagious origin of phthisis as a 
doctor of the sixteenth century, or an Italian or Spanish peasant 
of the present day. For him reunions of consumptives constitute 



70 Mary Putnam Jacobi 

more deadly foci of infection than cholera hospitals, and the 
lives of the patients sent to Nice and Cannes are terribly short- 
ened by the atmosphere impregnated with emanations from the 
reeking lungs of their fellow-sufferers. 

Upon this point especially does M. Pidoux attack the inno- 
vator. He charges him, not unfairly, with having entirely 
neglected the clinical study of tuberculosis in his absorption in 
its anatomical pathology. Examination of lungs after death 
is extremely useful as a means of ascertaining the results of disease 
and many of its processes, but must usually be incompetent to 
determine its cause. And it is glaringly illogical to conclude 
that because in a given case a disease has been artificially pro- 
duced by inoculation of certain substances from without, there- 
fore all spontaneous cases of the affection depended on the same 
mechanism. As well argue that capillary bronchitis could only 
be caused by injection of snuff into the trachea. 

Yet precisely to this complexion has come M. Villemin. He 
formally denies the possibility of any spontaneous alteration 
of the organism, and insists that all disease must result from the 
infliction of exterior agents. Thus, from the reformed basis of 
phthisis, he dares attempt the reform of all pathology. But, as 
Pidoux observes, all exterior agents would be without effect 
were it not for a susceptibility on the part of the organism to be 
affected, which capacity itself constitutes a spontaneity and 
individuality. 

In the meantime M. Pidoux is far from claiming for phthisis 
that overwhelmingly predestined character with which it is 
popularly associated. He admits that about one-sixth of all 
consumptive patients contract the disease in virtue of direct 
hereditary influence, but that many others are predisposed on 
account of transformed hereditary influence; arthritism, herpctism 
syphilis, or scrofula in the parents, tending less to reproduce 
themselves in the children than to occasion pulmonary tuber- 
culosis. 

Similarly, phthisis springs up in the wake of many diseases, 
which at their height are directly antagonistic to it. This is the 
case especially with arthritism, whose remains seem as it were 
to enrich the soil of the economy, and prepare it for phthisis. 
Such transformation takes place with the same individual. But 
in hereditary transmission M. Pidoux announces as a sufficiently 



Letters to the Medical Record 71 

definite law, the progress of capital or initial diseases, first 
towards mixed diseases, then those that are ultimate or organic. 
Thus arthritism, scrofula, syphilis, capital diseases, change into 
herpetism, neuroses, neuralgias, catarrhs, etc., or mixed diseases; 
and these in turn degenerate into organic diseases, as tuberculosis, 
cancer, epilepsy, and incurable degenerations of the nervous 
centres. M. Villemin entirely denies any connection between 
scrofula and tuberculosis, which is the more singular as he cannot 
ignore the readiness with which the lymphatic glands become the 
seat of cheesy degenerations, such as he identifies with tubercle. 
It is precisely because he is forced to admit the multiple origin 
of scrofula, that he seeks to separate it from tuberculosis, of which 
the specific character must be preserved at all hazards. Pidoux, 
fully conceding the difference between the two diseases, justly 
insists on their frequent etiological connections. Scrofula is the 
initial chronic disease, often superficial, curable, and not an 
organic malady, although capable of becoming so. Tuberculosis, 
and especially pulmonary phthisis, are ultimate and organic 
diseases, too often the final stage of non-tuberculous affection. 
It is quite as necessary for scrofula as for arthritism or syphilis to 
degenerate before it gives rise to tuberculosis; patients with 
scrofulous ulcers are not consumptive, but lymphatic constitu- 
tions, delicate, nervous, "civilized," fall an easy prey to phthi- 
sis, often because of their escape from the external manifestation 
of the disease. 

Finally, it is unquestionable that a number of persons un- 
tainted by hereditary vice of constitution, and uninjured by 
previous disease, fall victims to consumption on account of 
exposure to cold, to want, to privations. Pidoux seems to imply 
that in these cases the disease commences in bronchitis, deter- 
mining proliferations of alveolar epithelium, which degenerates 
into cheesy masses, which ultimately excite a crop of tubercles by 
irritation of the connective tissue. Pidoux, therefore, fully 
admits the German distinction between pneumonic phthisis and 
granular phthisis ; the last being constitutional, the fi.rst accidental, 
and often extremely rapid. Bouchard adheres also to this view, 
and sums up the differences between the gray tubercle and yellow 
masses, which nearly, if not quite, demonstrate their indepen- 
dence of origin. In the first stages of the "cheesy pneumonia," 
as the yellow masses are called by the new-school pathologists, 



72 Mary Putnam Jacobi 

the alveoli are found partially filled with large pavement cells, 
which, in spite of M. Villemin's assertions, reveal their epithelial 
character by being more or less soldered together. The alveoli 
also contain serous exudation. On the contrary, the first stage 
of the granulation consists of a mass of small spheric cells, 0™ ^, 
008 in diameter, with the nucleus filling the cavity almost com- 
pletely, closely pressed against each other. This mass is situated 
not in the alveoli, but in the connective tissue at the bifurcation 
of the blood-vessels. In the second stage of catarrhal pneumonia 
the liquid is absorbed, the anatomical elements accumulate 
and become infiltrated with fat, and presently the alveoli are 
rendered entirely impermeable to the air, and offer on section 
a smooth level surface uniformly gray and homogeneous. The 
granulations also submit to the cheesy degeneration, but for a 
long time retain their form, so that different zones are dis- 
tinguishable in their mass. 

Villemin's second thesis, therefore, which constitutes his 
remarkable discovery, is everywhere confirmed, and it is an ac- 
quired fact that it is possible to produce pulmonary phthisis 
artificially, by inoculation with tubercular deposit, or with the 
products of the pneumonia accompanying, determining, or 
determined by that deposit. But his first theory, that identifies 
the ^tubercle and the pneumonia, and his third, which would 
make of phthisis a specific virulent disease, seem to be sufficiently 
refutable and refuted. 

I only mention in passing the theory of contagion, for that is 
confessedly based on no clinical facts, but those dubious ones 
that have already done service for this theory. M. Villemin 
seems to infer that the contagion of phthisis must be a necessary 
consequence of its inoculability. But this is evidently a strained 
conclusion, since the conceivable mode of transmission between 
human beings must be widely different from that practised by 
Villemin on his rabbits. The hateful practical consequences 
of this doctrine of contagion may justify, perhaps, a partiality for 
M. Pidoux's vehement denunciation of its possibility. I have 
ventured to devote so much space to this discussion (of which I 
have endeavored to render the substance, but have been unable 
to transfer the zest and animation) , because it is one of the most 
important that has taken place in Paris for some time. The 
daily urgent practical need of interest in pulmonary consumption 



Letters to the Medical Record 73 

is so great that even a scientific vagary that should rouse the 
flagging attention to a worn-out theme, would be of value. This 
book of M. Villemin's, however, is no vagary or frivolity, as you 
may judge from the elaborate report that has been made of 
it to the Academy, and from the spirited debate to which it has 
given rise. But, in spite of its ability, and the great interest of 
the experimental researches, it is a reaction in a sorrowful direc- 
tion. All hopes of curing phthisis depend upon its nature as a 
general disease of common origin; and the theory which tends 
to make it specific condemns the physician to inertia, or the vain 
revival of forgotten specific antidotes. It is with pleasure, 
therefore, that I find that M. Villemin's arguments are less sound 
than they are brilliant, imposing, and endowed with the charm 
of novelty. P. C. M. 

Paris, January 2, 1868. 

Concerning Aphasia. 

To the Editor of the Medical Record, 

Sir — Americans are bound by every natural principle to 
oppose the tendency to centralization, which, like a dose of 
hashish, serves to concentrate the consciousness of entire France 
upon its head, Paris. We may most profitably and agreeably ful- 
fil this duty by giving a hospitable reception to the medical 
and scientific news so richly furnished by the provinces. 

One of the most interesting memoirs that have appeared 
during the past fortnight was read at the Imperial Society of 
Medicine, at Marseilles, by Dr. Fabre, wherein are discussed, 
with much clearness and originality, three problems concerning 
aphasia, a disease whose symptoms and pathology are so remark- 
able and mysterious. 

A fourfold division is made of the disease. In the first 
variety or degree the patient forgets words; in the second, he 
loses voluntary control over their formation; in the third, he 
ceases to understand their meaning ; finally, all these conditions 
may coexist in the most complex form of aphasia. 

The loss of the faculty for written language, which is so 
remarkable a secondary phenomenon of aphasia, also exists in 
four degrees. In the first, the patient loses all recollection of 
written letters or words, but is able perfectly well to copy models 



74 Mary Putnam Jacobi 

placed before him. In the second, he is unable to write, even 
when understanding what he wishes to transcribe. In the third 
case, he has lost the faculty of reading; and if he tries to write, 
although he succeeds sometimes in forming the letters well, he 
cannot co-ordinate them into words. Finally, all understanding 
of written or spoken language may have been completely 
abolished, while the rest of the intellectual faculties remain 
completely intact. 

It is remarkable that when aphasic patients are unable to 
express their wishes, either by words or gestures, they sometimes 
succeed in giving utterance to their feelings. Thus, a lively sense 
of gratitude inspired a patient at Hotel Dieu to utter the only 
word that he pronounced in the ward; he said "merci" to the rSH- 
gieuse who was taking care of him. 

In the first class, there are various degrees of forgetfulness. 
Some patients forget proper names, or the greater number of 
substantives, and express their meaning by circumlocution. 
Thus, instead of asking for a pen, they demand something to 
write with. Others cannot construct a complete sentence. In 
the second class the patients pronounce words differently from 
what they intend; and although conscious of their mistake, 
and irritated by it, they are unable to rectify it. After this 
simple perversion of language comes real impotence ; the patients 
express all their meaning with the same word, or even syllable, 
often utterly devoid of sense. Thus a patient of Trousseau's 
always repeated the word consist, and the syllable tan constituted 
the entire vocabulary of a patient of Broca's. With these pa- 
tients the movements of the tongue are perfectly free, and there is 
not a trace of glosso-labio-pharyngeal paralysis. 

In the third category, the functional trouble is less grave, 
as regards the mechanism of speech, and more serious in respect 
to intellectual disorder. The patients cease to understand the 
meaning of their own words, and when they wish to say one thing, 
express a meaning directly the opposite. Thus a lady receiving 
visitors, addressed them in terms of gross insult, supposing that 
she simply invited them to be seated. 

In the most complete cases of aphasia, from the testimony of 
certain physicians who have been affected by it and recovered, 
the intelligence is still perfectly intact. Thus Rostan observed 
his own case, and mentally prepared a clinical lecture upon it. 



Letters to the Medical Record 75 

Lordah, and Dr. Spalding of Berlin, had a similar experience. 
Whatever difficulty is encountered in intellectual exertion is not a 
cause of the aphasia, but a result, on account of the loss of signs 
necessary to give precision and support to thought. 

M. Fabre enters at length into the discussion of the anatomical 
locality for the lesion in aphasia. He inclines entirely to the 
opinion that, in the majority of cases, the left frontal lobe is the 
seat of the disease. Four or five cases have, however, been 
reported, in which a destruction of both the anterior lobes was 
unaccompanied by any symptom of aphasia. In these cases, 
however, the posterior part of the lobes was nearly intact. 
Moreover, M. Fabre suggests, although the faculty of speech be 
specially localized in this part of the brain, that in case of need, 
other portions might sometimes supplement its action. 

Again, autopsies of aphasic patients have not unfrequently 
revealed lesions of various parts of the encephalon, other than 
the frontal lobe. But it is easily conceivable that the fibres from 
this locality, in passing through diseased portions of brain 
substance, should become affected, even though their centre re- 
mained healthy. In this case the cause of the aphasia would 
be no indication of the seat of the faculty of speech. It is 
presumable, moreover, that there exist varieties in the lesions, to 
which the clinical varieties correspond. In permanent aphasia, 
the lesion generally consists in softening, especially such as results 
from obliteration of the middle cerebral artery. Such obliter- 
ation frequently determines a hemiplegia at the same time, on 
account of the distribution of the artery to the corpus striatum. 
In cases of sudden hemiplegia, M. Fabre considers that the coin- 
cidence of aphasia alone permits the diagnosis of obliteration 
instead of hsemorrhage, as the cause of the accident. 

Transitory aphasia either depends upon neuroses, as hysteria 
or epilepsy, or is attributed to congestions. But M. Fabre is 
incHned to rule out this last circumstance, and substitute obliter- 
ations of artereoles, which caase a temporary derangement of the 
nutrition. After a while the development of collateral circu- 
lation renews the nutritive activity of the region, and the 
patients recover. 

No therapeutic indication can at present be based upon this 
fact of arterial obliteration as the most common cause of aphasia, 
but it may tend to prevent the trial of useless or untimely measures. 



76 Mary Putnam Jacobi 

Pulmonary Emboli as a Consequence of Congelation of the 
Limbs. 

At Strasbourg, the opening lecture of the course of operative 
surgery, delivered by Professor Michel, consisted in an interest- 
ing study upon pulmonary emboli as a consequence of congelation 
of the limbs. At first sight this consequence seems to be ex- 
tremely far fetched, but the links are easily traced by means of 
such experiments as those made by M. Powchet on animals. 
The following are the conclusions of a memoir submitted by him 
to the Academy : 

1st. The first phenomenon produced by the cold is the 
contraction of the capillary vessels to such an extent that no 
globule can enter them. 

2d. Presently the blood globules begin to alter, become 
granular, opaque, crumpled on the edges. If only the limbs 
have been frozen, about the fifteenth or twentieth part of the 
globules are altered; but if the entire body has submitted to the 
cold, nearly all the globules are disorganized. In this case, the 
animal dies inevitably. 

3d. When the congelation is partial, the frozen part is 
destroyed by gangrene. If it be of small extent, the amount of 
disorganized globules poured into the blood is often not sufficient 
to compromise life. 

4th. If a large extent of surface has been frozen, and then 
suddenly thawed, so that a quantity of disorganized blood glo- 
bules are thrown into the circulation, the animal is liable to die on 
account of this alteration of the blood, and by no means in 
consequence of stupefaction of the nervous system. Hence it 
follows that the chances of life are increased in proportion to the 
moderation with which the thawing-out process is conducted. 

M. Michel, supported by the case of a patient at the hospital, 
who exhibited symptoms of asphyxia after her frozen feet had 
been thawed, admits that the danger results, not merely from the 
presence of disorganized globules in the blood, but their presence 
in the pulmonary capillaries. The accidents occur only after 
sufficient time has elapsed for the formation of clots from dead 
globules, then separation from the main mass in the large veins, 
and their arrival in the lungs. Here are found obstructing the 
capillaries, long clots, containing little whitish grains which seem 
evidently to be formed by altered blood globules, fat globules, and 



Letters to the Medical Record 77 

fusiform epithelial cells. The more recent clots surrounding 
these grains, and the infarctus found in the pulmonary paren- 
chyma, prove an arrest of the current of blood in the lung, on 
account of their presence in the capillaries. These lesions ex- 
plain the symptoms observed in such cases, the frequency of the 
respiration supplementing the impermeable portions of the lung, 
the presence of rales due to the sero-sanguinolent exudation that 
succeeds the embarrassment of the circulation, the bluish tint of 
the face, coinciding with a certain pallor of the skin. Death 
may result from syncope caused by the simultaneous formation 
of a great number of the pulmonary emboli in the capillaries, or 
even, and more suddenly, by the obstruction of the pulmonary 
aorta itself. Larrey relates a case during the Russian campaign, 
where this seems to have happened: "The chief pharmaceutist, 
Zurean, arrived at Kawno, exhausted with hunger and cold, 
and passed several hours in a warm room. Immediately his 
frozen limbs became swollen, and he expired without uttering a 
word." 

One of two destinies is reserved for the microscopic clots of 
blood globules. They either degenerate, and in consequence of 
their molecular disorganization the capillaries are reopened; or 
they organize by means of the development of fusiform cells, and 
then the capillaries are definitely obstructed. The method of 
elimination from the general circulation is at present unknown. 

In either of the foregoing cases, the patient may recover. 
The danger is aways in proportion to the extent of the lesion, 
and the suddenness with which it is produced. 

Uterine Retroversion During Pregnancy 

Dr. Vignard, of Nantes, communicates to the Journal de V 
Quest, two observations of uterine retroversion occurring, one at 
the third month, the other at the fourth month of pregnancy. 

In the first case, a difficulty of micturition existed for several 
days, and was followed by an attack at night of acute hypogastric 
colic, accompanied by intense vesical tenesmus. In the morning 
these symptoms abated, to give place to severe pains in the back 
and the groins, and particularly, a most painful pressure on the 
rectum. On examination, a tumor was discovered in the hypo- 
gastric region, extending 10-12 centimetres above the symphysis. 
This was formed by the distended bladder. 



78 Mary Putnam Jacobi 

By the vaginal touch, an immobile tumor was discovered, 
extending from the sacral concavity to the pubes, and forming 
to the vagina a convex roof, perfectly uniform, but slightly in- 
clined downwards and backwards. The neck of the uterus was 
discovered with difficulty, forcibly pressed against the upper 
part of the posterior face of the pubes. No fluctuation was per- 
ceived between the hand placed on the vesical tumor and the 
finger pressed against the tumor in the vagina. Pressure on the 
abdomen did not in the least affect the roof of the vagina. 

The bladder and rectum were evacuated by the sound, and 
an injection, and the physician then attempted the reduction of 
the uterus. After various methods had been tried in vain, the 
following proved succe?sful : 

The patient was placed on the back, the head tolerably 
low, the thighs separated widely, the feet on two high chairs, and 
the pelvis supported on a pillow placed at the edge of the bed. 
The physician then introduced the four fingers of the right hand, 
one after another, into the vagina, and taking with the left hand a 
point d'appid on the pubes, he forcibly pushed the uterus in a 
direction directly upwards. The tumor did not budge. Upon 
this the tactics were changed, and the operator directed his 
fingers forcibly, but with extreme slowness, toward the sacro- 
vertebral angle, gliding around the tumor, and keeping the radial 
border of the hand as near as possible to the pubic arch. It was 
tolerably easy to arrive at the promontory, and at the same mo- 
ment the uterus seemed mobilized. Upon withdrawing his hand, 
Dr. Vignard discovered the neck of the womb returned to the 
centre of the vagina. Abdominal palpitation discovered the 
body of the uterus above the pubes, replacing the void that had 
been left after the evacuation of the bladder. The only indica- 
tions afforded during the operation that the reduction had been 
effected, were the slight mobility of the uterus, and the contact 
of the fingers with the sacro-vertebral angle. Dr. Vignard 
thinks that the operator may be sure that he has succeeded, every 
time that the diameter sacro-sus-pubien can be occupied by the 
radial border of the hand. 

The patient was recommended to recline upon the abdomen 
during the first day, and the uterus retained its normal position. 
The subsequent pregnancy and the accouchement were un- 
accompanied by accident, but the child, who had vomited bile in 



Letters to the Medical Record 79 

the amnion, continued to vomit after birth, and died in seventeen 
hours, with the signs of acute peritonitis. 

In the second case, the third degree of retroversion seemed 
to have been attained, and the vaginal cavity was completely 
occupied by a globular body, warm, firm, elastic, that seemed to 
be the posterior face of the uterus. The neck forcibly flexed, was 
discovered high up behind the pubes. The retention of urine 
was considerable, but easily relieved by catheterism. The 
reduction was first attempted by the attending physician, but he 
found it impossible to raise the uterus above the superior strait. 
M. Vignard then practised the manoeuvre already described. 
The four fingers were pushed directly backwards in the sacro- 
pubien diameter of the pelvis, while the radial border of the hand 
pressed forcibly against the pubic arch. The pressure was as 
moderate as possible, to avoid injury to the foetus. At the 
moment that the fingers touched the upper part of the sacrum, a 
faint crackling sound was heard, the resistance was felt to be 
vanquished, and the vagina free. On withdrawing the hand, 
the neck of the womb was found returned to its place. The 
patient continued her pregnancy in safety, and was delivered at 
term of a healthy child. 

M. Vignard passes in review several methods that have been 
proposed for remedying this serious accident of retroversion. 

The method of Burns consists in placing the patient on the 
belly, and keeping the bladder perfectly empty by repeated 
catheterism. This method can only be successful in the first 
degree, in which the long axis of the uterus is parallel to the sacro- 
pubic diameter. This, however, was the case in Vignard's first 
observation, but the method was tried and failed. 

Boyer's direction, to draw down the neck of the womb at the 
same moment that the body is pushed upwards, is regarded as at 
least superfluous, since the neck returns of itself when the im- 
mobility of the body has been overcome. 

Moreau's plan of hooking the index finger around the neck, 
is condemned as futile. 

Negrier introduces the entire hand into the vagina, and pushes 
the uterus en masse as in certain methods for reducing hernias. 
A very large surface is here attacked at once, the tumor is flattened, 
and the inferior portion therefore increased in size, so that the 
method is more painful and more difficult than that of Vignard. 



8o Mary Putnam Jacobi 

M. Vignard rejects all methods by the rectum, because the 
hand will find more difficulty in reaching the promontory by this 
route than by the vagina, and all eflforts to push the uterus di- 
rectly upward tend merely to press it against the promontory which 
forms an insuperable barrier to its ascent. In resuming his own 
method, M, Vignard observes, that before directing the fingers 
toward the sacrum, he pushes upward on the anterior part of the 
uterus, and then glides toward the body of the organ behind. 

Tumors of the Tongue and Pharynx — New Operation 

M. Desgranges publishes in the Journal de Lyon, certain 
considerations on tumors of the tongue and pharynx, and a special 
method for operating upon them. This method belongs to M. 
Sedillot, and consists of a section of the lower maxilla on the 
median line, by means of which the two halves of the bone could 
be drawn aside and sufficient space left to excise the tumor. The 
wound of the soft parts heals readily, but for the cicatrization of 
the segments of the maxilla it was found necessary to maintain 
the adjustment by means of pincers. This instrument presents 
certain inconveniences, and M. Desgranges has used metallic 
sutures instead, piercing the bone with a drill, for the passage of 
the silver wire. 

Two cases are related where this operation was successfully 
performed for an epithelial cancer of the floor of the mouth. In 
the first case, the tumor, situated under the tongue, extended 
from the first molar of the left side to the canine at the right. 
The posterior face of the maxilla was invaded, and the incisors 
and left canine were partially loosened from the alveoli. 

In operating, the integuments were divided as far as the hyoid 
bone, then the section of the maxilla effected by the chain saw. 
Care was taken that the section should be made at the left side, 
and the insertions of the genio-hyoid and genio-glossal muscles of 
the right side avoided. Upon separating the segments of the 
bone, the diseased parts were easily removed with curved scissors, 
without touching the subjacent muscles. No blood fell into the 
pharynx, so that suffocation was avoided. The results were 
most happy. The tongue retained its movements, and no trouble 
occurred in the respiration. The two halves of the maxilla 
were not displaced, and when the patient left the hospital three 
weeks after the operation, a fibrous callus united the segments, 



Letters to the Medical Record 8i 

and with sufficient solidity to permit movements of the entire 
jaw. 

In the second case, the tumor had burrowed more deeply, and 
was ulcerated. The superficial layers of muscles were removed, 
but enough remained to insure the movements of the tongue. 
The operation, performed exactly as in the preceding case, 
was followed by a slight attack of erysipelas, and it was a month 
before the two halves of the divided maxilla ceased to shake 
in the movements of the lower jaw. But in six weeks the osseous 
union was complete. 

This preliminary osteotomy opens a free route to the bis- 
toury ; it enables the operator to examine the entire tumor, and to 
pursue its prolongations, a circumstance essential as a guarantee 
against relapse. Moreover, the extreme difficulty of ligating 
the numerous arteries encountered in this region is greatly pal- 
liated, and finally, the danger avoided of suffocation during the 
anaesthetic sleep, on account of blood flowing into the larynx. 

P. C. M. 

The Appointment of Hospital Internes in Paris — Interesting 
Cases from Cliniques of M, Gosselin 

To the Editor of the Medical Record. 

Sir — I cannot resist the opportunity to say a word on the 
admirable system that obtains in Paris for the regulation of the 
hospital studies of the pupils. Admirable both for its democratic 
equity in throwing open the best clinical advantages to all who 
choose to try for them, and for the stimulating pressure that it 
exerts on the mental exertions of the young men. Instead of 
private cliques surrounding each hospital physician — consisting 
of his paying students, to whom his only equivalent for three 
hundred dollars is the prospect of nomination to a vacant place 
in the wards — there is a perfectly free competition by means of 
nomination before a jury. 

Two sorts of places are directed to be filled by the students in 
the hospitals. The lowest is that of externe. An exteme is 
obliged to be on hand at every morning visit (a certain number 
of absences in the course of a year occasions the forfeiture of the 
place), and with his companions, records the prescriptions, and 
performs certain personal services required for the patients, as the 



82 Mary Putnam Jacobi 

dressing of wounds, application of blisters, &c. A definite 
number of externes is attached to each service, the number vary- 
ing, of course, with the extent of the service. To secure a place 
in this body, a medical student inscribes himself for the tria- 
examinations, which are conducted on two year subjects given at 
the moment, one pathological, the other anatomical. Two 
examinations take place at each concours. In the first the candi- 
dates prepare written answers to the questions, during a half 
hour allotted for the purpose. Upon the results of this prelimin- 
ary examination, a certain number of candidates are estimated, 
and the selected minority are submitted to a second final examin- 
ation of the same nature, but which is oral. The number of 
places to be filled each year, is sufficiently large to give nearly 
every serious student a chance for the external. 

For the place of interne, corresponding to what we call 
resident physician, the externes alone are eligible candidates. 
There are about forty-five places, and two hundred and eighty 
competitors. 

The examinations (which occupy two or three months) are 
of the same character as those of the external, only considerably 
more difficult. An externe generally calculates to compete 
twice before he succeeds in becoming interne. To prepare 
for these competitions, the candidates hold conferences in groups 
of twenty or thirty, that continue throughout the year previous 
to the moment of trial, and in which the entire outlines of internal 
and external pathology are passed in review. 

An externe is nominated for three years, an interne for four; 
and each year is passed at a different hospital. A person may 
become a competitor for either position at any stage of his medical 
studies at which he feels himself sufficiently jort to stand the 
examination. 

It is plain that the benefits of this system — great as they are 
to the students who succeed at the examinations — extend also to 
those who fail, since all are equally compelled to prolonged, 
thorough, and systematic work. No one can observe the work- 
ing of the method without wishing for its introduction at home. 

Another excellent custom in relation to the management of 
hospitals, is that of making the visit between eight and nine 
o'clock in the morning. M. Gosselin, the successor of Velpeau, 
for instance, is always on hand at eight precisely, and calls 



Letters to the Medical Record 83 

the roll of the students with the exactitude of a drill sergeant. 
Woe betide him who has overslept himself, and who, in spite of a 
breakf astless race through the quarter, arrives after the feuille de 
presence has been laid upon the table by the inexorable chief. 

"Why is this ulcer not dressed, sir?" demands the surgeon, 
fixing the trembling externe with his bright black eyes. 

" I, I — excuse me, I was late. I meant to do it after the visit." 

"Attend to it immediately, and never tell me again that you 
were late. That is no sort of reason for neglecting your duty. 
You are not to be late." 

All honor to men who, knowing their own duty, know also how 
to keep others up to the mark. All shame, confusion, and per- 
plexity to those who, careless, indulgent, or shiftless, permit 
things to be left undone that ought to have been done — after the 
fashion of all miserable sinners! 

As M. Gosselin's clinique lasts three hours, his extreme 
punctuality alone saves for the student the bulk of the day 
intact, and able to be employed at lectures, dissections, libraries, 
etc. After experiencing all the benefits of this system, I feel a 
certain horror of that prevailing in New York, where the visit is 
made at any time between twelve and three, subject to all sorts 
of variations dependent upon the exigencies of the physician's 
clientele or caprice. 

Cases of Metrorrhagia 

Two cases of metrorrhagia have formed for M. Gosselin the 
themes of recent and interesting clinical lectures. In the first 
case the haemorrhage had come on after a suppression of men- 
struation during two months, and the question of spontaneous or 
provoked abortion immediately suggested itself. M. Gosselin 
recapitulated the circumstances of the diagnosis which led him to 
rest finally upon this suggestion. The uterine orifice was neither 
granulated nor occupied by a polypus. Neither cancerous nor 
fibrous tumor could be discovered. Ballottement of the uterus 
was somewhat painful. The body was sufficiently voluminous 
to be felt in the hypogastrium ; the orifice sufficiently open to 
permit the introduction of the index finger. 

Under these circumstances, in spite of the affirmations of the 
woman that such contingency was impossible (affirmations which, 
as every practitioner knows, are precisely what create the delicacy 



84 Mary Putnam Jacob! 

and difficulty of the diagnosis), M. Gosselin did not hesitate to 
pronounce for an abortion. Principally on account of the denial 
of the patient, the inference was further drawn, that the abortion 
was deliberate. The haemorrhage ceased spontaneously, shortly 
after admission to the hospital, and the principal danger that 
remained to fear, was that of a metritis, determined by the 
instrument that had been employed. Hence, while active 
treatment was superfluous, active surveillance was impera- 
tively required. 

The other case was much more serious, and was first men- 
tioned in connection with the autopsy of its subject. 

The patient had arrived in a state of exhaustion, too great to 
admit of a precise examination, but complaining of an abundant 
uterine haemorrhage. Small vegetations were discovered around 
and within the os uteri, which, though apparently different from 
the tumefaction of cancer, proved at the autopsy to be carcino- 
matous, A hard tumor of some size was discovered behind and 
above the vaginal cul-de-sac. M. Gosselin could not decide 
satisfactorily to himself whether the body of the uterus was 
simply inflamed, or the seat of a cancerous tumor. 

The day after admission the patient was seized with a most 
intensely acute peritonitis. The constipation was obstinate, and 
presently accompanied by vomiting of matters that, though 
destitute of stercoral odor, resembled the contents of the small 
intestine. It was not the green liquid usually vomited in peri- 
tonitis, nor that tinged with brown occasionally observed, but 
distinctly brown, and characteristic of intestinal obstruction, 
especially a strangulated hernia. No trace of hernia, however, 
could be discovered, and the conclusion was arrived at, that 
the obstruction was caused by intestinal adherences dependent 
upon the peritonitis. 

At the autopsy, adhesions between the intestines and uterus 
were found in fact to be sufficiently extensive, and the intestines 
were so agglomerated around the pelvic cavity, that separation 
of the organs was attended with considerable difficulty. Behind 
the uterus was a cavity as large as a man's fist, circumscribed by 
the loops of intestine, by the uterus, and the abdominal walls, 
and containing a quantity of faecal matter, poured out from the 
intestine by three or four large openings. 

Such openings constitute an unusual lesion under the circum- 



Letters to the Medical Record 85 

stances. According to M. Gosselin, the uterine cancroid, which 
extended from the neck into the body of the womb, had been the 
point of departure of the whole train of circumstances. The 
irritation of this tumor had first developed the effusion of plastic 
lymph between the uterus and the intestines, which united 
these organs by the firm adhesions noticed above. Extension of 
this subacute inflammation had gradually thinned the coats of 
the intestine, until, at a given moment, the internal tunic gave 
way, and the contents were poured into the pelvis, exciting the 
acute peritonitis which had carried off the patient. The in- 
creased obstruction, upon which depended the stercoraceous 
vomiting, was evidentl3^ as had been supposed, the result 
of the rapid formation of lymph during the period of acute 
inflammation. 

Empyema and its Treatment by Perpetual Drainage. 

An extremely valuable clinique was that held by M. Gosselin 
on a case of empyema, that he had had under his eyes for two 
years, and in relation to which he suggested several ideas that are 
not everywhere current. 

Until recently (observed the Professor) suppuration of the 
pleura was regarded as a necessarily fatal disease, both on account 
of the exhaustion induced by the long continued drain on the 
system, as also by the habitual coexistence of grave pulmonary 
disease. No cure is possible unless on the condition of entirely 
evacuating the pleural cavity, which can only be effected spon- 
taneously by the establishment of a bronchial or cutaneous fistula. 
In a few cases children have been known to recover after the 
establishment of the first kind of fistula, or vomica, as it is techni- 
cally called, but only uncertain reliance can be placed upon the 
benignity of this mode of evacuation, and no physician has the 
right to provoke it. On the other hand, the cutaneous fistula is 
even more dangerous, air insinuates itself into the cavity, decom- 
poses the pus, and prevents the dilatation of the lungs, which 
gradually assume a state of definite collapse. Hectic fever sets in 
with all its train of symptoms, cough, diarrhoea, and ever5^hing 
indicating the absorption of purulent matters, and the patient is 
generally carried off in two or three months at the furthest. 
Modem surgery, however, has ventured to interpose the oper- 
ation of thoracentesis as an attempt to arrest the fatal march of 



86 Mary Putnam Jacobi 

this serious disease. This operation, whether performed by 
simple puncture or by incision, is (according to GosseHn) essen- 
tially the same, and essentially useless unless accompanied by a 
certain precaution presently to be described. In the first case 
the little wound speedily cicatrizes, and a repetition of tappings, 
is required, which finally results in the establishment of a fistula. 
By this the pus indeed escapes, but the air also enters, with the 
consequences above described. The same thing is true of an 
incision, and although there was more chance of success after 
Sedillot suggested counter-openings, and the use of injections to 
wash out the cavity, the results were still far from satisfactory. 
M, Chassaignac, however, has had the happy idea of inserting 
by the two openings perforated caoutchouc drainage tubes, 
which afford free and continual exit to the pus, and thus neutralize 
any evil effects resulting from the inevitable ingress of air. For 
the pus, however decomposed, is innoxious if able to freely escape, 
instead of being shut up in a close cavity, and stimulating its own 
absorption. 

In addition to the use of drainage tubes, injections of warm 
water are made every two or three days. The patient who fur- 
nished the occasion for these remarks, had been treated by the 
method above described, which had proved remarkably successful. 
He had first come under the care of M. Gosselin two years ago at 
La Pitie, and appeared then in a dying condition, exhausted 
by a long standing empyema and thoracic fistula. As soon as 
free exit was afforded to the pus, and the drainage tube estab- 
lished, the hectic fever began to mend, the patient's strength 
rallied, and in three months the convalescence seemed so solidly 
established, that the drainage tube was removed, and the man 
left the hospital. The flow of purulent liquid had entirely ceased. 
After working for about three months the patient began a second 
time to suffer from oppression. A fistula reopened, and after 
some weeks the general health had fallen to nearly as desperate 
a condition as on the first occasion. Readmitted to La Pitie, and 
treated again by a drainage tube, the patient again rapidly 
recovered. After this experience, the tube was left permanently 
in place. A third time he had run down in strength, and entered 
La Charite, but was speedily built up again by the same treat- 
ment, and thoracic injections of iodine and of sulphite of soda. 
It was M. Gosselin's intention to leave the drainage tube in place 



Letters to the Medical Record 87 

until the pleural cavity should be entirely obliterated. And this 
practice, and the theory upon which it is founded, constitutes the 
original part of his lecture. He declares that it is absurd and 
chimerical to hope that a serous membrane that has undergone 
a pyogenic transformation, can ever regain its original character 
or functions. So long, therefore, as it exists, so long will there be 
drainage from renewed secretion of pus. But by prolonged 
care in carrying off the corroding secretion as it forms, the sur- 
geon may hope for the formation of adhesions which shall 
definitely obliterate the cavity, and constitute the cure of the 
disease. 

By means of these combined methods, therefore, judiciously 
applied, many patients, in even grave stages of hectic fever, may 
be snatched from the jaws of death, and restored to a tolerable 
degree of health. This, of course, cannot be expected if the 
empyema complicates advanced tuberculous disease. 

M. Gosselin also applies the system of perpetual drainage to 
abscesses situated under the great pectoral, and whose evacuation 
is rendered difficult by the tonicity of the muscle. A case of this 
kind, actually in the ward, is doing extremely well. The tube, of 
course, passes through the original and the counter incision. 
Injections are made every two days with warm water. 

Psoas-Iliac Abscess. 

A very different kind of abscess was that presented by a case 
admitted January 7th. This was a young woman, of rather lym- 
phatic temperament, who had suffered for six months with pain in 
the sacrum, and, for a month in addition with pain in the left groin. 
In complete repose the patient was conscious of no suffering, but 
the least movement awakened the pains, as also pressure in the 
affected regions. Lying on her back, the patient was unable to 
completely extend the left thigh, and forced flexion of the limb 
was painful ; when the patient attempted herself to flex the thigh 
on the abdomen, the lumbar vertebrae arched forward. This 
same forward projection of the lumbar part of the spine was very 
evident in walking, when also the patient limped, and rested 
principally on the right leg. You will recognize this curvature as 
a symptom of insufficiency of action on the part of the psoas 
muscle. It would seem to be an instinctive attempt, by bringing 
the fixed insertions of this principal flexor of the thigh in a direc- 



88 Mary Putnam Jacobi 

tion approaching a perpendicular to the lesser trochanter, to 
supplement the intrinsic deficiency of power by the more favor- 
able direction in which it was enabled to act. 

Still another sign was obtained by placing the patient on the 
abdomen, and after seizure of the ankle, bringing alternately 
the right and left limb into forced extension. The left offered 
a resistance altogether abnormal. Finally, deep pressure in the 
groin, just above Poupart's ligament, detected an obscure tume- 
faction, though not fluctuation. 

In forming the diagnosis, M. Gosselin first set aside the possi- 
bility of lumbago, which would have tormented the patient even 
during repose, and been probably accompanied by rheumatism 
elsewhere; and of uterine disease, indicated by no other symp- 
toms; and arrived at the discussion of some different forms of 
spinal disease. The pain in the sacrum must in fact be referred 
to an ax rection of the spinal cord itself, of its membranes, or of its 
bony casement. In the first two cases, however, the sensibility 
or mobility of the limbs could hardly fail to be affected while the 
patient in question offered no sign of lesion of either. There 
remained, therefore, only arthritis of the sacral vertebras, which 
tended to terminate in suppuration, if that were not already 
commenced. 

On the other hand, unquestionable symptoms (recapitulated 
above) indicated inflammation in the neighborhood of the psoas 
muscle. The possibility of simple chronic psoitis, or inflam- 
mation of the surrounding cellular tissue, was eliminated on 
account of its extreme rarity, except as a consequence of puer- 
peral inflammation. There remained, therefore, after combin- 
ation of all the facts, the conclusion of a psoas-iliac abscess by 
congestion, resulting from caries of the Itunbar or sacral 
vertebrae. 

The prognosis (pursued the Professor) is excessively grave, 
and contrasts strikingly with the apparent benignity of the dis- 
ease at the present moment. Sooner or later, the abscess will 
probably open, and the patient succumb to exhaustion from the 
discharge. The only chance is that derived from the use of ton- 
ics, and the local application of iodine with the faint hope that 
the contents of the abscess may be absorbed. Even in that case 
the spinal disease would continually tend to occasion the form- 
ation of another. 



Letters to the Medical Record 89 

Danger of Apparatus in some Cases of Fracture of Jaw. 

Three different cases of fracture, one of the lower maxilla, one 
of the fibula, and one of the radius, furnished the occasion for 
some pointed and suggestive remarks. The first case was the 
result of a kick received on the jaw, and the fracture, though 
distinctly indicated by crepitation, was accompanied by but 
slight displacement, and an insignificant wound of the mucous 
membrane. The accident was therefore slight in reality, but 
Gosselin pointed out a certain possibility of grave danger from 
an unlooked-for source. He declared that whenever, as in this 
case, a solution of continuity had been effected inside the mouth, 
the application of any apparatus for holding in place the frag- 
ments of the jaw-bone w^s extremely mischievous. In two cases 
observed at La Pitie, irritation of these machines induced exten- 
sive inflammation of the mucous and submucous tissue, 
ultimately reaching the bone, and exciting osteitis, followed by 
denudation, necrosis, purulent absorption and infection, and 
death. Even where death is not the result, the necrosis compels 
an elimination which often lasts four or five months. 

In view of these possible perils (upon which, says Gosselin, 
authors have not sufficiently insisted), all apparatus should be 
proscribed, and the fragments retained in place by a simple 
bandage. The slight deformity resulting from lack of perfectly 
accurate adjustment, is more than compensated by the security 
for the life of the patient. 

Treatment of Fracture of the Radius, etc. 

Similarly, was an unexpected complication indicated as the 
occasional result of an accident so simple and seemingly harmless 
as fracture of the radius. The danger is again due to want 
of care in the application of the apparatus. A patient comes to 
the consultations the first day of the accident to have the bone 
"set" and arm splints adjusted, and insists on returning home, 
where he will be withdrawn from surveillance. The second or 
third day the arm swells and becomes so intensely tightened by 
the splints that, if they be not removed, the inflammation may 
result in gangrene. Gosselin had seen some examples of this 
consequence. 

In the case in question, when the patient returned to the 
hospital, after suffering for two days with sharp lancinating pains 



90 Mary Putnam Jacobi 

and sense of constriction in the arm, the limb was found greatly 

swollen, and a bright red streak on the back indicated the ap- 
proach of gangrene. This was happily warded off by the removal 
of the splints, but the danger had been imminent. 

It is, therefore, a rule with M. Gosselin, in all cases of fracture 
of the arm, especially with female patients, children, or old people, 
to wait during four or five days after the accident for the appli- 
cation of the splints. During this time the part is kept con- 
stantly poulticed, and at the end the inflammation is found to be 
well reduced, and no difficulty opposes itself to the setting and 
adjustment of the fragments, as the callus has still hardly begun 
to be formed. 

For further precaution, such an apparatus is selected as shall 
leave the limb open to observation. Tampons of cotton, wool, 
and then stout rolled compresses are placed against the free 
ends of bone to press them into place ; a splint is adjusted to the 
posterior and anterior face of the arm, and retained by two or 
three bands of diachylon. 

In the case of fracture of the fibula and external malleolus, the 
leg was placed, after adjustments of the fragments, in a simple 
plaster casing, formed of bands of tarletan, dipped in liquid plas- 
ter. This was chosen because it alone becomes fixed in a few 
minutes, while dextrined, gelatinized, or silicated bands require 
some time to attain the necessary rigidity. Where, therefore, 
the fracture only involves a small bone, as in this case, and there 
is less dread from the possible breaking of the case, M. Gossdin 
thinks that plaster is preferable to all other material for immobility. 

Dangers of Erosions of Urinary Passages in Cases of Retention 
— Reab sorption of the Retained Urine — Uraemia. 

The case of a man who died shortly after admission to the 
hospital for a retention of urine caused by urethral stricture, 
furnished opportunity for an acute suggestion from the lecturer. 
During life, the sinister progress of the disease had been sus- 
pected to depend upon concealed inflammation of the kidneys, 
possibly an abscess, whose presence was betrayed only by the 
purulent infarction which proved fatal. But at the autopsy, 
the kidneys were found to be perfectly healthy, and some small 
erosions of the urethra and the bladder were the only lesions 
discovered to explain the death. 



Letters to the Medical Record 91 

These lesions, however, were not sufficiently extensive to 
have caused death directly, but their indirect agency might be 
explained in one of two ways. It might be supposed that one 
or both kidneys had ceased to secrete, their functions being 
interrupted by sympathy with the interruption of the excretion. 
In this case, death would result from intoxication, caused by 
accumulation of urea in the blood. But the patient had exhibited 
no signs of coma, nor the fever characteristic of ordinary ureemic 
intoxication. M. Gosselin inclined to adopt the other theory, 
which suggested reabsorption of the retained urine, at the eroded 
surfaces of the urethra and bladder. A special uraemia would 
therefore result, betrayed by somewhat anomalous sjmptoms, 
but leading to definitely fatal results as that dependent upon 
suppression of urine. 

M. Gosselin explained that his reason for insisting upon this 
mode of fatal termination, was to point out the danger of even 
small erosions of the urinary passages, in cases of retention of 
urine from any cause. With the possibility of this danger in 
mind, the surgeon would often be much more careful than at 
present, to avoid tearing the mucous membrane by any instru- 
ment employed in treatment. 

Diagnosis of Cancerous Stricture of Rectum. 

Nearly at the same time, a patient died with stricture of the 
rectum, and in exposing the result of the autopsy, M. Gosselin 
recapitulated the clinical details of the case. The patient had 
entered the wards only eight days previous to his death, and at 
that time the stricture was so narrow that the little finger of the 
surgeon could hardly penetrate into the rectum across it. Below 
the stricture the finger perceived a rough mammillated surface, 
and the tissues around the narrowing were extremely hard and 
resistant. These circumstances, joined to the profound emaci- 
ation and exhaustion of the patient, excited some suspicion of 
cancer. But it is rare that cancer is equally disseminated over all 
the surface of the rectum, or produces a stricture so narrow or so 
near the sphincter. Cancerous stricture is never impassable to 
the finger, as was the lesion in question. Moreover, a cancer 
would not have remained rigid so long a time, but ulcerated 
considerably before the five years that had elapsed since the 
beginning of this one. 



92 Mary Putnam Jacob! 

Cancer being eliminated, the diagnosis turned upon fibrous 
thickening, probably of course under the influence of syphilis. 

An operation was decided upon, and two or three incisions 
were made at the level of the stricture. Before the operation, 
however, the patient had been attacked with a chill and some 
fever, both of which returned with renewed intensity afterwards, 
and death occurred in consequence of purulent infarction. A 
metastatic abscess was found in the lungs. 

Locally, the autopsy revealed an abrupt stricture, caused by 
hypertrophy of fibrous tissue, and accompanied above its upper 
border by a large shallow ulceration of the mucous membrane of 
the rectum. A certain amount of pus covered the surface de- 
nuded of epithelium. This ulcer, said the Professor, added 
greatly to the gravity of the disease, determining the tenesmic 
diarrhoea which had exhausted the patient, and probably con- 
stituted the immediate cause of death. 

P. C. M. 

The Catalogue of the U. S. Army Medical Museum, and a 
Foreigner's Estimate of the Medical Resources of Amer- 
ica — ^Two Interesting Cases of Ovariotomy — The Use of 
Drainage Tubes — Guerin's Pneumatic Occlusion. 

Paris, February 9, 1868. 
To the Editor of the Medical Record. 

Sir — The Archives of Medicine, in a very complimentary 
note, acknowledges the gift of the catalogue of the United States 
Army Medical Museum. 

Every one interested in the advancement of medicine and the amelioration 
of the health of armies, ought to feel indebted to the American Government for 
the gigantic and costly enterprise which it has just undertaken. The magnifi- 
cent volume which has been sent us by the liberality of the Surgeon -General 
cannot fail to be of immense utility, even to us to whom the rich Museum 
is inaccessible. Thanks to the summary observations which it contains of 
each piece registered in the Museum, we are able, in a great measure, to study 
the collection as if it were under our eyes, and shall in the future have the means 
of controlling the quotations of American surgeons who shall take their illus- 
trations from the Museum. 

Our administration is not accustomed to such generous initiative in the 
distribution of official reports to the journals. It has been necessary for the 
American Goverrunent to have the honor of giving the example, and of meet- 
ing, with the most laudable munificence, the silent wishes of the medical press. 



Letters to the Medical Record 93 

A Foreigner's Estimate of the Medical Resources of America. 

I met, the other day, a young Norwegian surgeon, with hair 
as yellow and eyes as blue as became a countryman of the Viking 
who had been spending some months in the study of this Mu- 
seum, and expressed for it the most unqualified admiration. "I 
cannot understand," he said, "why you Americans should take 
the trouble to come to Paris to study surgery; your facilities at 
home are worth fully as much, if not more, than all you can get 
here." 

Cases of Ovariotomy. 

Certainly no one need come to Paris to study ovariotomy. 
M. Richet, than whom a more distinguished surgeon is hardly 
living, has just had the misfortune to add another to the list of 
failures in this formidable, but sometimes successful operation. 
He had undertaken the extirpation of the cyst, to comply with 
the urgency of a brother physician, who considered the case 
remarkably favorable. M. Richet, however, pronounced an 
unfavorable prognosis, on account of a circumstance, which he 
has been subsequently led to consider sufficiently characteristic 
to serve as a formal contra-indication to an operation. The 
abdomen of the patient was the seat of a fluctuating timior, 
apparently a unilocular cyst ; but it had not the form which should 
have been given by a cyst of so considerable size. Instead of 
being prominent towards the middle, and advancing as it were in 
a point, the belly was rather flattened, and much enlarged at the 
sides, but not at all prominent in the middle. In the meantime 
the surface was even, and no sign existed of a division of the cyst 
into cavities; the unequal juxtaposition of whose walls might 
explain the flattening of the abdomen. 

M. Richet could not well account for this circumstance, but it 
inspired him with an indefinable apprehension of evil conse- 
quences, an apprehension only too well realized. For when, after 
incision through the integuments and subperitoneal tissue, both 
of which were thickened by adipose tissue and much infiltrated, 
the surgeon arrived in the cavity of the peritoneum, the most 
solid adhesions were discovered, uniting the cyst to the abdominal 
walls. The first could be turned with the hand, but they pres- 
ently became so solid as to resist all efforts. Convinced that 
localized adhesive peritonitis and fibrinous adhesions were more 



94 Mary Putnam Jacob! 

readily formed in the pelvic cavity than towards the abdominal 
walls, M. Richet inferred that the obstacles met with in this 
latter locality would be re-encountered, and on even a more 
formidable scale, towards the base of the tumor. He therefore 
resolved to abandon the operation, and the incision was united 
with a few metallic sutures. 

The patient, however, died of peritonitis the next evening, 
and the autopsy fully confirmed the prevision of M. Richet. The 
cyst could only be separated from the abdominal wall by tearing 
a part of this latter; and in the pelvic cavity the adhesions v/ere so 
close, that a slow and careful dissection was required to remove 
them. The bladder and uterus were involved with the tumor. 
This had no pedicle, properly speaking; it was composed of a 
principal cavity, from whose wall were suspended, floating, 
several smaller cysts; it was nourished by means of its intimate 
and extensive adhesions, especially with the uterus. It is certain 
that the continuance of the operation would have been com- 
pletely impossible, since the isolation of the cyst was so difficult, 
even on the cadaver. 

The remarkable flattening of the abdomen was therefore 
accounted for b}'- the very solid adhesions which maintained it 
solidly fixed, and drawn downwards. In such cases, concludes 
M. Richet, ovariotomy should never be attempted. 

It is interesting to notice also, that in spite of the repeated 
attacks of peritonitis which must have occurred to produce the 
adhesions, the patient had never suffered any abdominal pain, a 
fact which had greatly conduced to excite the false hopes for the 
success of the operation. 

From Strasbourg, however, comes a note of better cheer. M. 
Koeberle has succeeded in saving a patient operated upon for an 
ovarian cyst, and that in spite of the most formidable 
complications. 

The patient was 43 years old, the mother of three children, 
and endowed with a vigorous constitution. She was affected 
with a mu'tilocular cyst of the right ovary, of which one of the 
subdivisions had ruptured eight months previous to the operation, 
and occasioned a grave peritonitis. From that time had set in 
ascites, emaciation, anaemia, and hectic fever. Towards the end 
of September tapping was performed, and about six litres of 
brownish liquid, partly serous and partly stringy, were with- 



Letters to the Medical Record 95 

drawn. After this the general health of the patient was notably 
ameliorated. Ovariotomy was practised on the 26th of Novem- 
ber, under the influence of chloroform. An incision was made, 
twenty-five centimetres in length, giving issue to three litres 
of reddish serum. Puncture successively of three divisions 
of the cyst, of which one furnished a yellowish, one a brown, and 
one a grayish liquid, altogether amounting to eight litres. There 
remained a multilocular mass, weighing two kilogrammes, which 
was easily removed after division of a few adhesions, which 
united it to the omentum and abdominal wall. The former 
adhesion, which contained large vessels, was destroyed with the 
actual cautery. The pedicle of the tumor, four centimetres 
long, was divided by a wire loop, by means of a slip knot. The 
abdominal cavity was well sponged out, and the incision united 
by means of four deep, and six superficial sutures. A glass tube, 
ten centimetres long, plunging in the pelvic cavity along the posterior 
wall of the uterus, was placed in the lower angle of the wound, to 
admit of a free escape of the ligtiids. The operation lasted three 
quarters of an hour. About 400 grammes of blood were lost. 

A pelvi-peritonitis occurred, which remained localized and 
disappeared rapidly under the influence of the free escape afforded 
to the liquids, and the half sitting position given to the patient. 
But the fourth and fifth day the patient became restless, and the 
pulse counted 130. On the sixth day the sleep was interrupted 
at two in the morning, the restlessness augmented to agitation 
and anxiety; the pulse, still at 130, became variable small, and 
irregular; inspirations thirty-six; sweats, coated tongue, diminu- 
tion of the urine, and tympanitis of the abdomen, all announced 
grave change for the worse. 

By the 7th the condition of the patient was extremely menac- 
ing. At five o'clock in the afternoon, the surgeon discovered 
dulness in the right flank, between the iliac crest and the hypo- 
chondrium, extending over a space about as large as the palm 
of the hand. There was evidently a collection of serum, formed 
during the last fifteen hours, and dependent upon a local peri- 
tonitis (probably connected with inflammation of the ovarian 
vessels), and which would not delay to become general. Bold 
measures were necessary, and on the spot, M. Koeberle made an 
incision in the centre of the dulness, about seven centimetres 
above the iliac crest. The patient was too feeble to be chloro- 



96 Mary Putnam Jacobi 

formized, so recourse was had to a local apparatus for the vapori- 
zation of ether, which sensibly diminished both the pain and the 
haemorrhage. After division of the tissues to the depth of six 
to seven centimetres, the peritoneum was discovered, and being 
opened, gave issue to about 150 grammes of reddish serum. 
This was completely withdrawn by means of a canula, the exterior 
wound united by a single suture, and a tress of lint, replaced 
subsequently by a glass tube, served to maintain external communi- 
cation with the cavity of the peritoneum. The local dulness had 
disappeared. The patient was placed in a half-sitting position 
and in a lateral decubitus towards the right side, in order to 
facilitate the escape of the liquids. 

The next day, the patient, who had been in a subcomatose 
condition exhibited a marked improvement. The pulse was 
between 118 and 125, and the respiration twenty-two. On the 
fourth day after the incision, the borders of the wound were 
invaded by an erysipelas, which extended about twelve centi- 
metres. Treated with tincture of iodine on the limits of the 
inflamed parts, the erysipelas was arrested on its third day. 

The third crisis attended or consisted in the evacuation by the 
rectum of gray purulent stools. The patient afterwards became 
more comfortable, but the tumefaction in the right flank re- 
appeared, and continued, and the surgeon was unable to reach it 
by sounds introduced, into the wound. Finally, on the eight- 
eenth day after the original operation, the purulent collection 
opened spontaneously by means of the large tube which had 
been left in the wound ; and a great quantity of pus escaped, and 
the flow continued during two or three days. The tumefaction 
diminished in proportion, and disappeared entirely. The tube 
was gradually shortenejd, and at the end of a fortnight the cicatriz- 
ation of the iliac wound was complete, as well as that on the 
median line, made for the extirpation of the cysts, and where a 
tube had constantly remained. In a month and a half after the 
operation, the health of the patient was perfect. 

The striking peculiarities of this remarkable case unquestion- 
ably belong to the successful plan of leaving the drainage tubes in 
communication with the peritoneum; and to the boldness which 
risked an incision of that membrane, to give issue to the products 
of a local peritonitis. General peritonitis was thus warded off, 
three distinct times — first, in connection with the original oper- 



Letters to the Medical Record 97 

ation, then at the moment of the subsequent tumefaction, and 
finally during the formation of the abscess. M. Koeberle 
remarks, that when in the course of peritonitis a collection of 
liquids has been formed, opening of the peritoneal cavity is far 
from presenting the same gravity as when the membrane is 
healthy. The pseudo-membranes which agglutinate together the 
intestines, have rendered possible the formation of circumscribed 
cavities in which the exuded liquids have been able to accumu- 
late, and these serous or purulent foci may be opened, without 
interesting the remainder of the peritoneal cavity. When these 
liquids, which have a great tendency to decompose and become 
fetid, have been evacuated, there is nothing to prevent washing 
out the cavity with injections of sulphate of soda or of phenic 
acid. By this means, the affection is reduced to a simple local 
peritonitis. 

M. Koeberle has performed nine ovariotomies during the last 
six months, and only lost one patient, and she was fifty years old, 
and had submitted eight times to paracentesis. 

The Benefits of the Drainage Tubes, 

The immense advantage to be derived from the practise of 
leaving a tube inserted in a cyst, to provide for the complete 
evacuation of its contents, is shown in a remarkable case of 
hydatid of the liver, cited by the Archives from an observation of 
Dr. John Harley. 

When the patient first consulted the physician, he was 
affected with an abdominal tumor of four years' duration, con- 
tinuous with the liver in the hypochondrium, and extending 
to within two fingers' breadth of the pubes and Poupart's liga- 
ment. Dulness extended from this point to the level of the right 
nipple. On percussion, fluctuation was evident in all parts of 
the ttmior. 

Three times in the course of the first eighteen months of the 
development of the tumor, the patient had suffered attacks 
of sharp pain in the abdomen and epigastrium, of which the first 
attack had lasted twenty -four hours, and the last fifteen days. 
He had never been jaundiced. 

From the seat of the tumor and its development, Dr. Harley 
diagnosticated an hydatid cyst of the liver. No treatment, was 
instituted. Two years later the patient retiixned, with the tumor 



98 Mary Putnam Jacobi 

somewhat increased in size. The girth measured forty-two and 
five-eighths inches, and under the influence of a sHght attack of 
local peritonitis, the cyst increased so rapidly, that in ten days 
the measure of the girth had increased to forty-four and a half 
inches. In view of this rapid development, it was decided to 
tap the cyst, which was done on the level of a line going from 
the xiphoid cartilage to the umbilicus. A clear colorless liquid 
escaped, whose complete evacuation occupied two hours. Eleven 
litres of this liquid were collected, and found to contain several 
broken cysts, the size of a filbert, and cysts unbroken, as large 
as a pea. The operation was well supported, and relieved the 
patient. The abdomen retracted, and by palpation, below the 
umbilicus, could be perceived the lower border of the cyst. 
The canula was left in place. 

The patient remained without fever till the eighth day, when 
the canula escaped from the wound, and all flow of liquid ceased 
during twelve hours. The cyst became distended and per- 
ceptible in both hypochondria, the skin hot, pulse 120. The 
canula was replaced, and immediately there escaped 250 grammes 
of a turbid liquid, dark yellow in color, and with a fetid odor. 
The febrile symptoms disappeared, while the flow was only 
interrupted by the fragments of hydatid cysts that from time to 
time blocked up the canula. When the obstruction became 
definite, the cyst was distended a second time, and grew painful, 
and the fever returned. On this occasion, an elastic sound, nine 
inches long was introduced into the cavity by the canula, and 
600 grammes of liquid were collected. About the same amount 
escaped during the course of the following fortnight, and occa- 
sionally, owing apparently to the rupture of some secondary cyst, 
the flow would become more abundant. 

The forty-third day the canula was entirely removed, but the 
elastic sound left in place. Up to this date injections had been 
made of water mixed with iodine or creasote, forty drops to a litre. 
On the fifty-first day, a considerable haemorrhage was produced in 
the cyst. The pulse immediately mounted from 96 to 140, and 
in the evening was 160. The skin became hot, dry, and yellow- 
ish, the cyst hard and distending the epigastrium and hypo- 
chondria, and the patient vomited repeatedly. 500 grammes of 
thick fetid sanguinolent liquid, resembling the blood which flows 
after the section of the liver, were withdrawn from the cyst. 



Letters to the Medical Record 99 

which was then carefully washed out with water, containing some 
creasote. During the following week, the iodine injection was 
replaced by a solution of twenty-five to fifty centigrammes of 
nitrate of silver, in some ounces of water ; afterwards an injection 
was made every morning and evening of a solution of four 
grammes of sulphate of zinc in 300 grammes of creasotized 
water. 

After several days, during which the stools were quite color- 
less, there was suddenly evacuated by the rectum a quantity of 
pultaceous matter, of a color analogous to that of the liquid 
coming from the cyst. A few days later, a great quantity of pure 
bile flowed from the wound, fifteen grammes being collected 
in some minutes. Communication was therefore evidently 
established, on the one hand with the intestine, on the other with 
the gall bladder. This was the fifty-third day. 

After various less important vicissitudes, it is noticed on the 
123d day, that no more bile escaped from the wound, that the 
cyst was greatly diminished in size, so that the sound, which had 
penetrated 9 and 10 inches, now extended only 4. On the 148th 
day, the flow had ceased, and the sound was withdrawn. Shortly 
afterward, the health of the patient being entirely re-established, 
he resumed his ordinary occupations. The girth had diminished 
13 inches. The dulness of the liver was normal, but the spleen 
remained hypertrophied. The heart had resumed its proper 
position. No trace remained of the tumor. 

Dr. Harley follows the recital of this interesting case with 
some general remarks on the treatment of hydatid cysts, in which 
he particularly insists on the necessity for favoring the complete 
evacuation of the cavity. He thinks that nearly all failures are 
due to neglect of this precaution and of any attempt to obliterate 
the hydatic membranes. If any liquid be left, it is sure to putrefy 
sooner or later, and infect the blood. Then follows a synoptical 
table of about 100 cases gathered from different authors. In 
thirty -four, a single opening had been made, followed by complete 
or partial evacuations of the liquid and immediate closure of the 
wound. There were eleven cures, thirteen ameliorations, and 
ten deaths. 

In the second table are thirteen cases treated by successive 
openings, with or without iodine injections; eight ameliorations, 
two cases without result, and three deaths. 



100 Mary Putnam Jacobi 

In the third table, containing thirty cases treated by one or 
several openings followed by prolonged communication with the 
exterior, there are twenty-three cures, of which at least eighteen 
may be considered radical, and only seven deaths, five of which 
must be attributed to a new accumulation of liquids which had 
been unable to escape, and had putrefied. In ten cases in which 
the tumor was opened by caustic potassa, were observed three 
cures, three ameliorations, and four deaths. Dr. Harley thinks, 
moreover, that the caustic presents no real advantage, and has 
the disadvantage of being much more painful than the other 
treatment. 

These results therefore tend to confirm the views expressed in 
connection with the operation for ovarian cysts, namely that 
the dangers do not depend upon the admission of air into, but the 
imprisonment of liquids within the cavities, natural or artificial. 
Escape, escape, escape for all these vile and noxious fluids — such 
is the watchword of a host of modern surgeons, in a host of cases, 
and the doctrine is perhaps best applied by M. Maisonneuve, in 
his apparatus that fulfils at once the double purpose of occlusion 
of the wound, and aspiration of the liquids at its surface or bur- 
rowing in its recesses. I believe I have already described to you 
this apparatus, or at all events it is well known to you, if only for 
the reason that every American physician who comes to Paris 
goes straight to the Hotel Dieu, to see it in operation. 

M. Gosselin, at La Charite, carries out the principle of free 
drainage for other purposes than that of preventing purulent 
infection. In case of cold and burrowing abscesses, with or 
without fistulas, he generally inserts a small perforated drainage 
tube by the original opening, at the same time exercising steady 
pressure upon the dilated walls of the cavity. In this way he has 
recently treated with marked success a case of indolent abscess 
burrowing under the great pectoral muscle, and has now under 
treatment an abscess at the malleolus, and another resulting 
from axillary adenitis; a case of rather diffused phlegmon of the 
neck was similarly treated, but succumbed to the erysipelas 
which had been imminent from the first day of the disease, much 
more before the insertion of the drainage tube. This instrument 
does not in any case seem to provoke superficial irritation around 
the wound, and what deep-seated irritation may be excited by 
the pressure of even such a mild foreign body as gutta-percha, 



Letters to the Medical Record loi 

does not seem to pass beyond what is advantageous for stimulat- 
ing the reparative powers of the secreting surfaces. 

Guerin's System of Pneumatic Occlusion. 

In a recent seance at the Academy of Sciences, M. Guerin 
gave a resume of the applications hitherto made of his system of 
pneumatic occlusion, — essentially the same as that of Maison- 
neuve to which I have just alluded. He ranks these applications 
under four categories. 

1st. Wounds and simple surgical operations such as incisions, 
ablations of cicatrices or of subcutaneous tumors, extractions of 
foreign bodies from articulations. 

2d. Grave operations, such as amputations of limbs, and 
accidental wounds of the same importance. 

3d. Contused wounds, openings of the skin, and simple com- 
plicated fractures, that is with perforation of the skin, while the 
bones are simply broken. 

4th. Wounds from fire-arms with dilacerations and destruc- 
tion of the tissues, fractures with crushing of the bones, and 
wounds uniting the gravest complications of traumatic lesions. 

In the most favorable condition, the pneumatic occlusion pro- 
duces cicatrization without traumatic fever, and without sup- 
purative inflammation; that is to say, it realizes union by first 
intention. 

In less favorable cases, and when the wound has already been 
a long time exposed, or contains foreign bodies, or, finally, is 
complicated with anterior morbid conditions, pneiunatic occlu- 
sion cannot prevent a certain degree of suppurative inflammation; 
but in virtue of the continuous aspiration which it exercises, it 
opposes all accident resulting from the putrefaction and absorp- 
tion of altered fluids, and in all cases favors, and renders much 
more rapid, the cicatrization, and consecutive organization of 
wounds. 

P. C. M. 

The Treatment of Abscess of the Liver by External Incision — 
Swallowing of a Fork — Perforation of the Stomach and Colon; 
Escape of Instrument through an Abscess in the Abdominal 
Walls — Treatment of Morbus Coxariusfrom a French point of 
view. 



102 Mary Putnam Jacobi 

Difficulties in Childbirth with an Abnormal Pelvis; Interesting 
Suggestion relative thereto — Cases of Complicated Rheumatism 
— Nux Vomica i?t the Dyspepsia of Hypochondriacs — 5m/- 
phide of Carbon as a Local Ancesthetic — Dextrine in Varicose 
Eczema. 

To the Editor of the Medical Record. 

Sir — The medical experience of any particular country on the 
diseases peculiar to the locality, serves somewhat as Professor 
Tyndal's lecture apparatus, which projects upon a screen the 
magnified representation of operations too delicate to be other- 
wise perceived by the audience ; for the characteristics of maladies 
that may be inadequately appreciated when observed only at 
rare intervals, become salient and striking when a nimiber of 
similar cases are massed together. Hence it is in the study of 
such masses of facts, that the practitioner becomes able to cope in 
his own climate with the exceptional cases of disease, for which, 
however infrequently, he is bound to be prepared. 

Abcess of the Liver, etc. 

Abscess of the liver, as every one knows, is as common in 
warm countries as it is rare in our temperate zone. The Medico- 
Surgical Society of Alexandria (Egypt), has just published 
the conclusions of a most interesting discussion on the treatment 
of this formidable degree of hepatic inflammation — conclusions 
that it cannot be uninteresting to relate to you. 

The turning point in the debate, was the question of the 
utility of puncturing the abscess, and a great number of cases 
were reported by different members of the Society, in which 
the effects of the operation could be compared with the march 
of the disease when treated less energetically. I give you the 
sum-total of the results, without entering into the details. 

The cases may be divided into two groups, the first comprising 
the abscesses not operated upon, the second, those upon whom 
the operation was performed. Each group is again subdivided 
into abscesses the size of a man's fist, called large, and all below 
this dimension, classed as small. 

The first group, abscesses not operated, contains 8i cases, 
among which there were 58 deaths, 14 cures, and 9 doubtful cases. 
The mortality was, therefore, 80.55 P^^ cent., the recovery 19.45. 



Letters to the Medical Record 103 

In the second group are 42 cases, of which were 21 deaths and 
21 recoveries — mortality 50 per cent., recovery the same. The 
first subdivision of the first class, in which the abscesses were as 
large as a fist, or larger, contained 24 cases, with 21 deaths, and 3 
recoveries — mortality 87.50 per cent., recovery 12.50. 

The second subdivision of this group (abscesses smaller than 
a fist) comprised 13 cases, of which 9 died, and 4 recovered — 
mortality 69.23 per cent., recovery 30.76. 

In the first subdivision of the second group (large operated 
abscesses), are 22 cases, 15 deaths, and 7 cures — mortality 68.18 
per cent., cures 31.81, 

In the second sub-class (small abscesses), are 10 cases, of 
which 3 died, and 7 recovered — mortality 30 per cent., cure 70 
per cent. 

It is noticeable that each group contains a number of cases 
in which the size of the abscess had not been determined with 
sufficient precision to rank it in either of the sub-classes. In view 
of these statistics, it was resolved by the Society that, 1st, in all 
cases of hepatic abscess, large or small, the chances for recovery 
are considerably greater if an operation be performed; 2d, that 
in cases of small abscesses the operation is so favorable that 
more than two-thirds of the patients are cured. 

Among the 14 cases unoperated upon, in which the patients 
recovered, in 1 1 the abscess opened spontaneously into the lungs. 
In two cases, the communication was effected with the intestine, 
and in one, with the stomach. But generally, whenever the 
abscess opened anywhere than into the lungs, the rupture proved 
fatal. This was the case 14 times, where the rupture occurred 
three times into the peritoneum, four times into the intestine, 
four times the pleura, once the stomach, once the pericardium, 
and once the locality is not specified. 

Death in all cases, whether following an operation, or occur- 
ring by the natural progress of the disease, was determined 
either by general hectic fever, or by uncontrollable diarrhoea. 
The latter was the most frequent cause of death after an un- 
successful operation, and generally occurred when the puncture 
had been delayed to an advanced period of the disease. It was 
indeed decided by the Society that the operation should be per- 
formed as soon as possible after recognition of the abscess, and an 
exploration made, even when the liver was scarcely painful and no 



104 Mary Putnam Jacobi 

fluctuation could be distinctly perceived. In default of the most 
salient symptoms, an experienced observer would almost always 
pronounce upon the existence of an abscess by the earthy tint 
of the complexion, accompanied by augmentation of the size of 
the liver; an extremely obstinate diarrhoea, yielding to no treat- 
ment; nocturnal sweats; often periodical fever, chills, and loss 
of appetite. It is affirmed that the introduction of the explor- 
ing trocar, even if the liver be healthy, is not followed by any 
serious accident. 

It was generally agreed that the use of caustic was to be 
proscribed, as being slow, extremely painful, and possessing no 
advantages over the bistoury. For the adhesive inflammation 
desired by the employment of the caustic, is invariably set up 
around the drainage tube, within 24 hours after puncture by the 
bistoury. 

It was asserted, moreover, that the action of the caustic 
is not well circumscribed, but is apt to occasion badly suppurating 
wounds. 

The persistence of the drainage tube is a most important 
element of the treatment. This tube is liable from time to time 
to become blocked up, in which case it may be withdrawn, cleaned 
out, and replaced. 

Swallowing of a Fork, perforation of Stomach and escape through 
abdominal walls. 

A most remarkable case of traumatic abscess is reported in the 
Medical Gazette of Strasburg, as occurring in an insane asyltmi at 
Zutphen. The patient was a w^oman 64 years old, affected with 
lypemania, who had swallowed a silver fork for the purpose of 
committing suicide. She was received into the asylum two days 
after accomplishing this feat, and the physician had no difficulty 
in detecting the foreign body in the stomach. The teeth of the 
fork were in the cardiac portion, directed upwards and forwards, 
the handle lying backwards, in the pyloric extremity. The 
patient complained of no pain, only a sensation of weight and 
oppression at the stomach. During the first days, she was sub- 
mitted to entire repose, severe diet, and expectation. A slight 
febrile reaction gradually established itself, and the patient 
at last complained of pain in the left epigastric region. These 
S5anptoms continued without aggravation during three months, 



Letters to the Medical Record 105 

and then gradually subsided. At this time the teeth of the fork 
disappeared from the place where for so long they had been 
plainly perceptible, and instead was discovered a singular tumor 
in the abdomen, to the left of the timbilicus, which occasionally 
had the air of a gravid uterus at four months. It was impossible 
to decide upon the nature of the contents of this tumor, in which 
no sign of the fork could be perceived. The pain was trifling, the 
pulse at 72 ; stools easily obtained by enemata. A slight febrile 
reaction occurred later, but the digestion always remained 
undisturbed. 

Five months later, the tumor, which till then had been 
quite round, began to point. The abdominal walls were not 
adherent. In the course of the following month an abscess 
formed; the integuments gradually reddened and thinned, and 
the tumor opened spontaneously, and gave issue, first, to a small 
quantity of pus, then to liquid faecal matters. About a week 
later, at the morning visit, the physician was surprised at per- 
ceiving the four teeth of a fork behind the abdominal wall, close 
by the fistulous opening. By prudent manipulation, it became 
evident that the foreign body was only retained in place by the 
integuments, and in effect, after a couple of lateral incisions, the 
fork was easily extracted in the perpendicular direction that 
it occupied to the abdominal wall. The handle was entirely 
surrounded by extremely fetid faecal matters; a great number 
of crystals of phosphate of lime covered the teeth of the 
fork, which had turned black from a coating of sulphate of 
silver. 

The patient, who during the last days had suffered a good 
deal of pain, was immediately relieved after extraction of the fork. 
The fistula was simply dressed, and healed without difficulty, a 
firm cicatrix being established by the end of a month. For some 
time longer, the neighboring parts remained infiltrated, but even 
this infiltration gradually disappeared, and the patient was 
completely restored to health. 

As the tumor had always remained on the left side of the 
abdomen, it seemed evident that the fork had not traversed the 
length of the intestinal tube, but passed directly from the stom- 
ach into the transverse colon, after an adhesive inflammation had 
established solid connection between the two organs. It was 
inferred that the crystals of lime salt had been deposited on the 



io6 Mary Putnam Jacobi 

teeth which had arrived in the colon, while the handle still 
remained in the stomach. 

It is extremely remarkable that the general health was so 
slightly deranged by the ten months' sojourn and peregrinations 
of a foreign body in the stomach and intestines. Perhaps the 
mental alienation of the patient may be presumed to have 
blunted the general physical sensibilities, a circumstance fre- 
quently observed in the pathology of the insane. 

Treatment of Coxalgia from a French point of view. 

M. Philipeaux, who has for some time made a sort of specialty 
of coxalgia and its treatment, has recently published a memoir 
upon resection of the head of the femur, in cases of this disease 
that have resisted general treatment, and are conducting their 
victims to the grave. 96 instances of this operation have been 
published, since it was first practised by Antony White, of Lon- 
don, in 1 821; and half the operations have resulted in radical 
cures. Surgeons have objected to this operation on the ground 
that it was unnecessary, since all curable coxalgias could be cured 
by general treatment; that it was fruitless, since the cotyloid 
cavity was always affected, as well as the head of the femur; 
and that any attempt to operate upon this cavity was too danger- 
ous, on account of its proximity to the pelvis. M. Philipeaux 
admits the seriousness of all these objections, but, in reply to 
the first, observes that the operation is only proposed as a last 
resource, in cases where all others have failed; in answer to the 
second he declares that the lesion of the cotyloid cavity has many 
more chances to heal, if relieved of the irritation caused by the 
presence of the diseased femur; and finally, although the danger 
of applications to a point so near the pelvic cavity is not to be 
dissimulated, yet the surgeon may in many cases be justified in 
cauterizing, with circumspection, the acetabulum with the 
actual cautery, and in all cases may remove the fungosities therein 
developed. The resection is contra-indicated when pulmonary 
phthisis, scrofula in the third degree, heart disease, or vertebral 
caries, complicates the coxalgia. Too great an extent of the 
local caries is also a contra-indication. The operation is 
favorable in proportion to the youth of the patient; and the 
following table of 67 cases shows clearly how success varies with 
age: 



Cures 


Death 


12 


7 


20 


10 


7 


3 


2 


3 


2 








I 



Letters to the Medical Record 107 

Cases Age 

19 5 to 9 years 

30 10 to 19 

10 20 to 29 

5 30 to 39 

2 40 to 49 

1 50 

Spontaneous luxation of the head of the femur is one of the 
most favorable conditions for resection, but is not, as was at first 
supposed, indispensable. In 32 cases operated, where this lux- 
ation did not exist, are counted 16 cures, 9 deaths, and 7 doubtful 
cases. 

The operation comprehends three periods: 

A . First Period. The patient is placed upon the sound side, 
with the trunk slightly raised, and the lower limbs extended. 
Aneesthesia, of course, is induced. 

The surgeon, standing at the right of the patient, feels for the 
upper border of the great trochanter, and by his incision describes 
a semi-lunar flap, whose convexity is inferior. All parts bur- 
rowed by fistulas should be included in the incision, and all parts 
removed which seem incapable of assisting in the cicatrization. 
The insertion of the trochanter muscles is divided, and the 
border of the cotyloid cavity attained. When all the articu- 
lation is carious, the capsule is swollen and often perforated. 
If it be yet intact, the limb is placed in flexion and abduction 
before dividing the capsule by a pointed bistoury. The mem- 
brane is then loosened above and below by means of a bistoury 
guarded by a button. In the majority of cases, the round 
ligament no longer exists; when it does, it is to be cut with this 
same instrument. 

B. Second Period. Luxation. — Forced luxation should al- 
ways precede section of the femur, except where the parts are 
united by osseous stalactites. When the femur is intact it is 
easy to use it as a lever, and execute with it movements of 
adduction and inward rotation, which rapidly drive the head out 
of the cotyloid cavity and the lips of the wound. 

C. Third Period. Resection. — A small board is then placed 
behind the dislocated head, the neck denuded of its periosteum 
(of which as much as possible should be preserved), and then 
severed by means of a straight or chain saw. If, on examin- 
ation of the surface of section, any diseased bone is found to have 



io8 Mary Putnam Jacob! 

been left, it is removed by a second stroke of the saw, which 
sometimes goes below the small trochanter. The great trochan- 
ter should be removed in any case, says M. Philipeaux, following 
Malgaigne, for if left, it will fit itself into the cotyloid cavity, and 
so oppose the free issue of pus. Finally, all articular fungosities 
should be removed, and if necessary, the acetabulum rasped, 
gouged, or cauterized. 

D. Consecutive Treatment. — After the operation is terminated 
the patient is placed in dorsal decubitus, and the sound side of the 
body somewhat elevated by means of oat cushions, so as to favor 
the flow of liquids from the wound. 

Mattressed gutters for the reception of the operated limb are 
rejected as useless, fatiguing, and greatly interfering with the 
dressing of the hip. M. Philipeaux prefers to simply support 
the patient by the cushions. In two classes of cases, however, 
it is necessary to maintain continued extension of the leg: ist, 
when the surgeon has been unable to place the femur in complete 
extension during the anaesthetic sleep. 2d, when, after a 
spontaneous luxation, the head of the femur had mounted high 
enough to occasion notable shortening, which persisted after the 
operation. 

The wound oniy requires simple treatment. The edges are 
drawn together at the two angles by bands of diachylon, while 
the middle is left open for the introduction of a few balls of lint. 
The whole is then covered with anointed linen, and with com- 
presses. This treatment may continue until the wound is filled 
up with fleshy granulations. If the suppuration is abundant, 
the wound should be washed two or three times a day with warm 
aromatic injections ; if there be danger that it close too quickly, a 
caoutchouc drainage tube is introduced. 

Before cicatrization is complete, it is well to accustom the 
limb to some slight movements, but only allowed gradually 
and with much caution. These movements are renewed and 
extended in different directions, so as to restore, if possible, 
mobility to the joint. Excessive exercise, however, is hurtful, 
as tending to produce too much laxity in the articulation. 

In the two most recent cases of resection, the patients pre- 
served the mobility of the femur, and recovered with a pseudo- 
arthrosis instead of an anchylosis. In Mr. Le Fort's memoir on 
the subject, twenty-seven patients are reported to have escaped 



Letters to the Medical Record 109 

with a perfectly useful articulation, and capable of walking very 
tolerably, although more or less lame. 

Permanent shortening of the limb is to be palliated, of course, 
by a raised metallic sole to the foot. 

DiflBlculties to Childbirth in Abnormal Narrowness of Pelvis. 

A curious calculation is made by Dr. Vignard in relation 
to the difficulties opposed to childbirth by abnormal narrowness 
of the pelvis. The reflection is suggested by a case occurring in 
his practice, in which the sacro-pubic diameter of the basin was 
eighty-nine millimetres. AH attempts to deliver the child by 
forceps proved unavailing, and the accoucheur was obliged to 
have recourse to craniotomy. 

The woman had already had three children, and according to 
the husband's account, the first two, though delivered with 
forceps, came into the world alive and well, and were still living. 
The third, he admitted to have been born dead, but was still 
delivered with forceps. All three were girls. After the patient 
had recovered from the effects of the labor (lasting forty-eight 
hours), and of the operation, the physician requestioned the 
husband, and ascertained that, in truth, craniotomy had been 
performed upon this last child. It was not surprising, therefore, 
that the fourth, which was a boy, should have required the inter- 
vention of the fatal operation. 

Hence the obstacle to delivery had continually increased with 
each successive birth. There was no reason to attribute this 
increase to any greater narrowness of the basis, but rather to what 
Dr. Vignard asserts to be a well recognized law, namely : that a 
woman's first children are always the smallest, and the size in- 
creases with each new birth. Thus, in this case, the first forceps 
delivery had been easy, the second difficult, the third accouche- 
ment required craniotomy, and finally, in the fourth, the mascu- 
line sex of the child introduced another cause of increased size. 
As a practical rule, therefore. Dr. Vignard recommends, when- 
ever an abnormal retraction of the pelvic cavity has been dis- 
covered, sufficient to require the forceps to draw the foetal head 
into the superior strait (of course, the application of forceps for 
any other reason would not count) , and especially when cranio- 
tomy had once been practised — in these cases he recommends 
when a new pregnancy occurs, that premature delivery be 



no Mary Putnam Jacobi 

provoked at the eighth month. For it may be regarded as cer- 
tain, that whatever difficulty has already existed, will be pre- 
sented again, and in a more formidable degree, and that a woman 
who has once lost a child by craniotomy, can never hope for 
living offspring, if she waits till term to be delivered. 

Cases of Complicated Rheumatism. 

M. BoucAND, of Lyons, reports several cases of grave rheiun- 
atism, severally complicated with pneumonia, albuminuria haemor- 
rhage, or encephalic accidents. 

In the first case, the patient was a man about 40 years old, and 
when first observed, after an illness of eight days, was in a demi- 
typhoid condition, manifested by general prostration, slowness 
of speech, dry lips, cracked tongue, great thirst, and slight 
epistaxis ; but without any eruption. The pulse was vibrant, and 
at 130 — slight cough, mediocre oppression, tubular breathing, and 
bronchophony at the summit of both lungs. The patient gave 
no sign of sensibility, except when his right thigh was touched 
or extended, when he screamed out. A rude bellows sound was 
heard at the base of the heart. 

The patient was thus affected at once with double pneumonia, 
endocarditis, arthritis of the right hip-joint, burning fever, and 
stupor. According to M. Boucand, all the other conditions 
were under the dependence of the abnormal rheumatism. The 
patient succimibed on the second day, but no autopsy could be 
obtained. 

The second patient was a woman of 34 years, admitted to the 
hospital with acute rheiunatism, compHcated by endocarditis. 
After admission, she was attacked with pleurisy, accompanied 
by very moderate effusion. The urine contained albumen at this 
time. The arthritis persisted at the knee and wrist, in spite of 
the pleurisy. Suddenly, the patient, who suffered from insomnia, 
but whose cerebral functions remained intact complained of 
excessive oppression, and sibilant and subcrepitant riles ap- 
peared in all parts of the chest. The patient died 36 hours after 
this invasion of pulmonary oedema. 

The third observation relates to a man 25 years old, attacked 
with acute rheumatism for the third time. He labored under 
arthritis of several joints, intense fever and sweating, and 
repeated and abundant epistaxis. The skin was covered with 



Letters to the Medical Record in 

sudamina; a soft, blowing sound was heard at the base of the 
heart ; bilious vomiting occurred several times. 

This patient recovered in 25 days, without preserving any sign 
of cardiac disease. 

At the same time was received at the hospital a woman four 
months advanced in pregnancy, attacked with polyarthritis and 
endocarditis. She was affected also with epistaxis and also 
spitting of blood. The skin was red, and covered with sudamina. 
This patient was seized with eclamptic convulsions several hours 
before dying. No autopsy could be made. 

In the fifth case, a lymphatic girl, aged twenty-two, was 
treated in September for acute rheumatism, and left the hospital, 
cured of the acute disease but in cachectic condition, and sub- 
ject to diarrhoea. She returned in a month, complaining of 
intense cephalalgia. Vomiting, nocturnal delirium, contraction 
of the maxillae and the muscles of the neck came on, and the 
patient died ten days after admission. 

Finally, another woman, 46 years old, was admitted on 
account of general feebleness and leucorrhoea, unaccompanied 
by organic uterine lesion. She suffered from no heart symptoms ; 
but a well characterized organic disease was discovered, and the 
patient acknowledged having had several attacks of rheumatism. 
The patient was put upon digitalis and a tonic course of treat- 
ment ; when, a week after her entrance, new symptoms suddenly 
declared themselves, beginning with moderate fever, complete 
stupidity, and anaesthesia and hemiplegia of the left arm. The 
left side of the face was paralyzed, the tongue deviated; no reply 
could be obtained to questions ; complete prostration of strength, 
and loss of appetite. The urine contained albiunen. Four 
days afterwards arthritis of the right wrist declared itself, 
and immediately the intelligence returned, and the left arm 
recovered its motor power. A fortnight later, the albumen had 
disappeared from the urine, the intelligence remained intact, 
there was no more sign of paralysis, and the patient ultimately 
left the hospital in a very satisfactory condition. 

In connection with these two cases of meningitis (for so M. 
Boucand feels entitled to call them), produced under the influence 
of rheumatism, the writer reports several cases of adult meningitis 
occasioned by othe-^ diseases. In one case it was a pneumonia, 
occurring in a person addicted to intemperance. The meningitis 



112 Mary Putnam Jacobi 

declared itself during convalescence from the original disease, 
and at the autopsy the pneumonia was found to be in full course 
of resolution; but a soft exudation had developed between the 
arachnoid and pia-mater. In another case the cerebral disease 
came on during an anomalous variola, where the eruption was late 
and scanty, consisting at first of herpetiform vesicles. At the 
autopsy a layer of greenish pus, infiltered under the arachnoid, was 
discovered on the upper surface of the cerebellum and the inferior 
extremity of the spinal cord. In a third case, an erysipelas of 
the scalp was the primitive affection, but when delirium declared 
itself, the opinion of Trousseau, who declares this symptom to be 
insignificant in the course of this disease, invested the prognosis 
with an optimism which the autopsy of the patient thoroughly 
routed, for the signs of meningitis were evident. Finally, is a 
case of meningitis occurring during typhoid fever. The patient 
was nineteen years old, and died the 20th day of the disease. 
She had coma and stupor, dorsal decubitus, fall of the eyelids, 
deafness, cephalalgia, dilatation of the right pupil without 
strabismus. The pulse was 100, the skin dry, and the temper- 
ature thirty-eight in the armpit. The jaws were so forcibly 
contracted as to render examination of the tongue impossible. 
Sensibility of the skin remained sufficiently keen; there was iliac 
gurgling, and retention of urine with distension of the bladder. 
A certain amount of contraction existed in the muscles of the 
neck and back ; the thorax was sonorous on percussion, but there 
were sibilant and crepitant rales, constipation persistent, and 
vomiting of liquid ingesta. Three days before death hallucin- 
ations occurred, with contraction of the wrists and carphology, 
and the patient ceased to recognize her mother. Several attacks 
of epistaxis and tracheal rales preceded the death, which occurred 
in the midst of a continually increasing dyspnoea. The urine 
evacuated by the sound was red and extremely foetid. 

This case is extremely interesting from the curious mixture 
of the symptoms severally characteristic of the two diseases 
which found themselves in presence, and from the manner in 
which the meningitis gradually obtained the ascendency over 
the fever, so that at last it seemed to rule alone. But at the 
autopsy, the reality of sloth in enteritis was well demonstrated by 
two grayish ulcerations in the ileum and at the ileo-coecal valve. 
The meningitis was evidenced by a sero-albuminous effusion in 



Letters to the Medical Record 113 

the anterior subarachnoidal space ; by the thickening and vascu- 
larization of the pia-mater, everywhere adherent to the brain; 
by adhesion of the two cerebral lobes at the fissure of Sylvius; 
by half a glass of thick whitish liquid, like whey, in the third 
ventricle. Neither pus nor tubercle nor gray granulation along 
the arteries could be found. 

M. Boucand remarks, that primitive meningitis is so rare with 
adults that, in presence of acute meningical disease, search should 
always be made for some other malady which has served as its 
cradle. 

Nux Vomica in the Dyspepsia of Hypochondriacs. 

En Fait de Therapeutique. — There are, as always, one or two 
items or suggestions worthy of being placed in the budget. Pro- 
fessor Trastour, of Nantes, has occasion to highly praise the 
emplojrment of nux vomica in all forms of atonic dyspepsia, and 
especially as a relief for the painful digestions so common among 
the hypochondriacs. His theory is based upon the two facts, 
that nux vomica stimulates and regulates the activity of the 
spinal cord, especially in regard to its reflex action, and that the 
integrity of the functions of the grand sympathetic is subordin- 
ated to the regular accomplishment of the functions of this part 
of the nervous system. 

The following is a useful formula : 

I^. — Pulv-nux vom. i — 4 grammes. 
Pulv. cassias ligne£e 2 " 
Carb. calc. or carb. mag. 2 grammes. 

M. — ft. pulv. 20. 

One powder at the beginning of each meal, in unfermented 
bread. 

M. Trastour, like many of his confreres, prefers nux vomica to 
the salts of strychnine, both on account of its innocuousness and 
its efficacy in dyspepsias. 

Sulphide of Carbon as a local Anaesthetic. 

Recent experiments have been made upon the properties of 
sulphide of carbon as a local anaesthetic, and have been very satis- 
factory. The cold induced is more disagreeable than by the 
volatilization of chloroform and ether, but the analgesia is more 



114 Mary Putnam Jacobi 

profound. A splinter of wood, encysted since two months, was 
easily removed under the influence of the sulphide of carbon, after 
the operation had been abandoned on account of the pain which 
persisted in spite of the local application of ether. 

Dextrine in Varicose Eczema. 

Finally, a suggestion in reference to the treatment of that 
obstinate disease, varicose eczema, cannot be inappropriate. 
It is recommended that the limb be swathed in linen bands, 
previously dipped in a solution of dextrine, made with 125 
grammes of dextrine to a litre of boiling water. Compresses, 
dipped in the same liquid, should be laid upon the limb previous 
to the application of the bandage. This is then allowed to dry, 
and only renewed when it tends of itself to unroll — that is, by 
the fourth or fifth day. The eczema should have become toler- 
ably dry before this application can be indicated. 

M. Devergie, whose name is of such authority in skin diseases, 
finds that his patients are infinitely better off with the dextrined 
bandage than with the laced stocking. The bandage is useful 
even without the dextrine, but the addition of this latter prevents 
the linen from becoming soaked with liquids, in which case it can 
hardly be removed without tearing a considerable portion of the 
epiderm. P- C. M. 

The Theories of the Dermatologists of the Hopital St. Louis. 

To the Editor of the Medical Record. 

Sir — Who, from the commander-in-chief to the smallest cor- 
poral in the vast army that wages war on disease, has not heard 
of the Hopital St. Louis ? Who, that makes the most flying visit 
to Paris, fails to contrive an excursion to its somewhat distant 
locality, for at least one walk through its great cool wards, 
through the brilliantly clean courts, and spots of refreshing gar- 
den? The whole forms a little city in itself, where the most 
repulsive forms of disease, assembled in an immense collection 
from all corners of Paris, and Europe, and the entire world, are 
stripped of a large share of their deformity by the influence of 
their surroundings, and a large share of their gravity by the 
enlightened skill of the brilliant coterie of physicians who make 
St. Louis the arena of their conflicts and triumphs. 



Letters to the Medical Record 115 

These conflicts, it must be confessed, are not exclusively 
carried on between the doctor and the bodies, or skins, of his 
patients. It is often a war intra muros, a rivalry of opinion 
among the physicians, which is sustained with such vehemence, 
that the spectator asks himself nervously, what would be the 
consequence if the chiefs of opposing camps should encounter 
each other in the morning at the narrow stairway that opens into 
the Hospital grounds? The meeting would be more critical 
than that of Raphael and Michael Angelo in the Vatican, and, 
perhaps to avoid its chances, the different physicians seem to 
arrange to arrive at their respective wards at different hours. 

The names that are at present associated with the pro- 
mulgation of any special doctrine, are those of Cazenave and 
Giebert, Devergie, Bazin, and his somewhat wavering satellite, 
Hardy. The two first are devoted pupils of Bielt, who himself 
was an ardent disciple of Willan and imported the classification of 
the English dermatologist at the very moment that in another 
ward at St. Louis, Alibert was proclaiming his, — and planting his 
arbre des dermatoses in the imaginations of an entranced audience. 

Their system, therefore — and I believe it is that best known 
in America — considers exclusively the primitive anatomical ele- 
ments of cutaneous eruptions, classified as: ist. Exanthemata; 
2d, Vesicules; 3rd, Papulse; 4th, Bullae; 5th, Squamse; 6th, Tuber- 
cles; 7th, Pustules; 8th, Maculse. Gibert classes lupus elephan- 
tiasis, and several other exotic diseases, under the head of 
Tubercles ; Cazenave makes of each of them, as well as Purpura 
and Pellagra, a class apart; and both recognize the Syphilides as 
a separate class. 

This system is certainly characterized by an extreme simpli- 
city, even an ostentatious absence of all pretension to theory or 
doctrine. Distrusting their own ability to discover any connect- 
ing links between the multiple phenomena of skin diseases, the 
authors confine themselves to making a simple statement of such 
phenomena, considered as purely local affections. In a volume 
published this year, M. Cazenave reiterates substantially his old 
principles, makes light of causes of diseases, which constitute the 
basis of Wilson's classification, entirely rejects scrofula even as an 
influence in dermatology, and only improves upon his original 
programme, by the introduction of certain researches into Patho- 
logical Anatomy, which, unfortunately, are more often hypotheses 



ii6 Mary Putnam Jacobi 

than researches. Thus he declares eczema to be an inflammation 
of the sudoriferous glands; impetigo, an inflammation of the 
lymphatic vessels; lichen, irritation of the papillae of the derma; 
but brings no microscopic proof of his assertions, which are more 
or less plausible. Bazin admits the probable lesion of the sudorif- 
erous glands in eczema. Devergie acknowledges that impetigo 
is generally grafted upon a lymphatic temperament; but Hardy 
observes that the papulae of lichen and prurigo do not bear the 
slightest resemblance to the normal papillae of the derm, either in 
their distribution, which in nowise recalls the regular concentric 
lines of the papillary stratum. 

In view of the double difficulty in the way of anatomical 
researches occasioned by the infrequence of mortality from skin 
diseases, and their cessation at the occurrence of any serious 
malady, it may be questioned whether, with the assistance of local 
anaesthetics, a physician might not extirpate from the skin of a 
living patient such a minute segment as would be needed for 
microscopical examination. Many obscure points would thus 
stand a chance of being elucidated. 

Besides this self-restriction to the anatomical characters of 
skin diseases, M. Cazenave is further noticeable (and especially 
in his recently published work on General Pathology of the Skin) 
for an entire rejection of vegetable parasites as intervening even 
in favus. Herein he is in complete accordance with the English 
dermatologist, Wilson. Now the rival school, composed of M. 
Bazin, supported by M. Hardy, and moderately admired by M. 
Devergie, is distinguished by its extensive adoption of crypto- 
gamic etiologies, by its discontent with "lesions" of the skin, as 
the ultimate explanation of its diseases, and by the research after 
general constitutional causes for all affections that are not parasi- 
tic in their origin. The theories of Bazin have been for some 
time on the carpet, but as I believe that they have not widely 
circulated on the other side of the water, and as they are ex- 
tremely interesting, and, if true, extremely important, I will 
expose them in some detail. 

The starting-point of the theory is to be found in the generally 
acknowledged existence of the great class of Syphilides, affections, 
which, though embracing the entire range of primitive anatomical 
elements, are all distinguished by characteristic features; copper 
color, circular form, white lisere (called Britt's, from the emphasis 



Letters to the Medical Record 117 

he laid upon this desquamation of the epiderm around a primitive 
element); blackish green crusts, grayish ulcerations with sharp 
indurated edges; smoothish but indelible cicatrices, etc. In this 
case the elementary lesion is common to specific and non-specific 
forms of disease; the affection, formed by the grouping of the 
elements, as an ecthyma, from pustules, ulcers, and crusts, is 
generally common also, although some forms are almost exclu- 
sively syphilitic ; but the malady, the general constitutional condi- 
tions upon which the affections depend, and which give them their 
significance, alone are separate and peculiar, alone assume a 
distinct individuality, requiring a distinct therapeutic treatment. 
So imposing is this individuality, that it overpowers all other 
considerations; should microscopic analysis demonstrate abso- 
lute identity between the lesions of specific and non-specific erup- 
tions, the prognosis and therapeutics of these latter would remain 
none the less dependent upon the diagnosis of the constitutional 
disease. 

Setting out from this universally acknowledged doctrine, M. 
Bazin has inquired if the great class of non-specific eruptions 
might not also be brought under the influence of constitutional 
diseases. The result of his researches has been the integration of 
three great maladies, whose individuality is as distinct, and 
relation to cutaneous affections as important, as those of syphilis. 
These maladies are. Scrofula, Dartre, and Arthritis, and I 
name them in the order in which they have gained public 
credence. D^vergie admits scrofula ; Hardy, scrofula and dartre; 
Cazenave and Gibert deny even scrofula as regulating skin 
diseases; finally, only the pupils of M. Bazin believe in the 
existence of arthritis. 

M. Bazin gives the following definitions of Maladies, Dia- 
theses, and Affections: — "A malady (or disease) is a state of the 
body which produces functional disorders, called symptoms, or 
material disorders, called lesions. A constitutional disease is a 
malady, acute or chronic, pyretic or apyretic, continued or inter- 
mittent, contagious or non-contagious, characterised by an 
assemblage of morbid products, and of extremely varied affections, 
attacking any or all the orgayiic systems. 

A diathesis is a malady, etc., characterized by the formation of 
a single morbid product that may be deposited in any or all of the 
organic systems. Tuberculosis and cancer are examples of dia- 



ii8 Mary Putnam Jacobi 



theses, and several others are admitted, the haemorrhagic, sac- 
charic, fatty, etc. 

An affection, is what we commonly call a disease of any partic- 
ular apparatus, as the skin, and corresponds to an assemblage 
of elementary lesions and symptoms, of which, however, it is not 
the cause but the statement. The cause resides in the constitu- 
tional disease. 

The problem of the diagnosis of any cutaneous disorder is, 
therefore, threefold. It is necessary to determine: ist, the 
anatomical element, as for instance the vesicle as distinguished 
from papulffi, pustules, etc. ; 2d, the affection, as an eczema, dis- 
tinguished from herpes, scabies, or other vesicular affections; 3d, 
the nature of the disease of which the affection is the expression 
for the time being — whether for instance, the eczema be scrof- 
ulous, or dartrous, or arthritic. Each case is characterized: ist, 
by objective peculiarities proper to the affections of each con- 
stitutional disease; 2d, by the coincidence of general symptoms, 
equally characteristic of such disease, even in the absence of a 
cutaneous affection. 

In the diagnostic of constitutional scrofula, M. Bazin does 
not greatly differ from the majority of physicians, with whom it is, 
of course, the most usual thing in the world to admit a scrof- 
ulous constitution, and to consider that it impresses a certain 
character upon some eruptions. Only Bazin calls a disease what 
others only name a tendency to disease ; the engulphs the lymphatic 
temperament (upon which Devergie greatly msists as predispos- 
ing to scrofula) with scrofula itself, and he entirely rejects 
Cazenave's restriction, for whom chronic inflammation, or 
tubercular degeneration of the lymphatic glands, constitutes the 
sole expression of scrofulous disease. 

Asstuning an exact parallel between the evolution of syphilis 
taken as a type, and all other constitutional diseases, M. 
Bazin divides scrofula into four periods, each characterized by 
peculiar affections, and the two first by special affections of the 
skin. 

First Period. — Mild cutaneous disorders, including Gourmes 
(which Cazenave regards as accidental, and Devergie as depur- 
ative), eczema, impetiginous eczema, impetigo; also dry scrof- 
ulides, erythema, prurigo, lichen, psoriasis, acne simplex in all 
its forms including acn^ sebacea ; scrof ulides_of the mucous mem- 



Letters to the Medical Record 119 

branes; habitual coryza, seropurulent otorrhoea; glandular 
blepharitis; dacriocystitis, with lachrymal tumor and fistula; 
scrofulous ophthalmia and keratitis ; reiterated bronchitis ; amyg- 
dalitis, stomatitis; certain tenacious diarrhoeas; certain in- 
flammations of the vulva and vagina. 

For all these affections, as will presently appear, with the 
exception of gourmes of the head in young children, M. Bazin 
admits the existence of other forms more dependent upon other 
diseases than scrofula. 

Second Period. — Profound cutaneous affections leaving 
cicatrices; lupus, both the erythematous and tuberculous variety; 
papulo-pustular scrofulides; impetigo rodens; certain serious 
forms of acnd, molluscum; also more obstinate affections of the 
mucous membranes, leucorrhoea, with erosions and granulations 
of the neck of the uterus ; blennorrhagia with enlarged prostate, 
and urethral stricture. 

To the Third Period belong affections of the bones and articu- 
lations, and to the Fourth visceral and parenchymatous lesions 
generally tubercular, with Hectic absent or slightly marked, 
although Bazin admits a tubercular diathesis independent of 
scrofulous disease. You instantly appreciate the difference 
between this view and that which takes into account scrofulous 
constitution and scrofulous diseases, but not a scrofulous disease, 
with a regular evolution and distinct degrees and stagings. Of 
the three (scrofula, dartre, and arthritis), it is scrofula that 
approaches most nearly to the standard type, but even here the 
critic is forced to object that M. Bazin often strains his analogy 
beyond the warrant of facts. Tertiary syphilis never occurs 
without having been preceded by primary and secondary symp- 
toms; while in scrofula, however frequent may be the instances 
of preliminary eczemas, impetigos, etc., M. Bazin himself admits 
that a cicatricial scrofulide, a lupus, may declare itself in a subject 
who has never suffered from any previous eruption. In this case 
he would claim that the links are supplied by some ganglionic 
scrofulide — some blepharitis, — and urge the example of syphilitic 
patients who suffer from osteocopic pains after the engorgement 
of the lymphatic glands has taken place, but without having 
exhibited any roseola, papulae, etc. 

M. Bazin of course does not pretend to make all the terms of 
scrofula correspond to those of syphilis. The initial infection 



120 Mary Putnam Jacobi 



lacking in the first disease, the affections of its first and second 
periods, correspond to those of the second in the syphihtic 
malady. The third and fourth periods resemble each other in 
the two diseases. 

Comparison of the objective characters of scrofulous affec- 
tions is best made after the description of the two remaining 
constitutional diseases. 

Dartre, as you know, is an old French word, formerly em- 
ployed to designate all eruptions except those of the head, which 
were similarly huddled together under the name of teignes. 
Alibert retained the term, though greatly modifying its accept- 
ation. Bazin, followed by Hardy, has revived the name, and 
applied it, not to a tendency, a habit of body, but to a distinct 
constitutional disease, with regular march, evolutions, symp- 
toms, etc. He has adopted as a synon3mi, though without 
clearly explaining why, the word Herpetic, as the general term 
to characterize eruptions dependent upon dartric disease. The 
evolution of the dartre is divided into four periods, preceded by 
more or less well defined 

Prodromata. — These — that would be more justly entitled. 
Indications of a predisposition — consist in: scanty transpir- 
ation, skin dry, irritable, subject to ephemeral eruptions; thin- 
ness; frequent diarrhoea; nervous affections, sick headaches, 
gastralgia ; a disposition irascible and melancholy. 

The First Period is marked by the appearance of pseudo- 
exanthemata, urticaria and zona. Eczema also is of frequent 
occurrence at this stage. 

Second Period. — Dry herpetides, psoriasis, pityriasis, lichen; 
secreting affections, eczema, dartrous impetigo, mentagra, pit- 
uite, blennorrhagia, leucorrhoea, rebellious diarrhoeas; often 
ascites, and hydropericarditis, increased irascibility, often in- 
sanity. 

Third Period. — The cutaneous affections tend to generalize 
themselves, and visceral disorders occur. 

Fourth. — Extreme emaciation; infiltration of cellular tissue; 
skin clinging to the bones, covered with scales, crusts, and in- 
flammatory exudations; hectic fever, death by syncope. 

Of course the only cases where the s^rmptoms of this fourth 
period are directly dependent upon cutaneous affections, are 
rupia, or pemphigus, and cachectic ecthyma. In all other 



Letters to the Medical Record 121 

instances a visceral disorder has been induced, under the in- 
fluence of the constitutional dartre. 

Before commenting on the substantiality of this pathological 
entity, I will quote the parallel description of arthritis, the third 
darling of M. Bazin's brain, and the most dearly loved of all, for 
the very reason that it is entirely ignored by the rest of the 
world : — 

Prodroma. — Exaggerated transpiration; tendency to obesity 
and development of the muscular system; constipation, haemor- 
rhoids, sick headaches, congestion of the head, epistaxis, vertigo, 
ringing in the ears, 

[This description applies evidently to persons with "a full 
habit," and subject to the inconveniences and consequences of 
constipation.] 

First Period. — Articular rheumatism; eczema of the scalp 
(before puberty, afterwards it is more disseminated); erythema 
of the external organs of generation; oedematous erythema 
around the articulations; urticaria, zona, herpes, acute pemphi- 
gus, furuncles and anthrax; coryzas, bronchitis and ophthal- 
mias; sick headaches and arthritic dyspepsia; vague muscular 
pains. 

Second Period. — Attacks of gout and of acute articular 
rheimiatism; cerebral congestions, anginas, obstinate coryzas; 
dyspepsia with burning at the stomach, pyrosis, constriction 
of the oesophagus; localized pruritus, especially at the nostrils, 
anus, and genital organs ; sometimes anal fissure. 

Third Period. — More serious lesions of the articulations, 
tophus, destruction of cartilages, caries of bones, ankylosis. 

Fourth Period. — Organic affections of the heart; congestions 
and apoplexies; catarrhal asthma; various lesions of the liver 
and kidneys. 

Although M. Bazin, in this extensive generalization, unites 
gout and rheumatism like a pair of Siamese twins, he by no means 
claims their identity. They both come under the great class 
Arthritis, but possess their individual and distinguishing char- 
acteristics. In the same way he attaches cardiac affections, not 
to rheumatism itself, as generally acknowledged, but to a more 
general condition, that embraces the two. 

The elaborate specification — which I shall presently expose — 
by which affections, similar, but belonging to different con- 



122 Mary Putnam Jacobi 

stitutional diseases, are distinguished from one another, will bring 
out into much stronger relief the peculiarities that are supposed 
to characterize these diseases, than this succinct generalization is 
able to do. But with that alone before us, we can fairly criticise 
its basis, to the extent to which that is independent of the cutane- 
ous disorders it professes to explain. Assuming — as I think can 
be proved — that cutaneous affections vary in four principal 
modes, conveniently designated as syphilitic, scrofulous, herpetic, 
or arthritic, and that to each of these modes is attached, more or 
less loosely, a liability to certain disorders affecting other parts of 
the economy, — we are not therefore obliged to conclude that 
each mode constitutes a disease, which constantly holds the 
patient in its clutch, menaces him even at moments that the 
temporary absence of all affections seems to leave him in perfect 
health, and can never be considered cured until it has completed 
its entire evolution, and been subdued at the fourth period. The 
proof of the existence of such a disease would be found in the 
regularity of its evolution, the absence of interversions, the 
constant reunion of a sufficient number of characters to establish 
its identity. Already scrofula — the nearest approach to the type 
exhibited by syphilis — begins to fail in some of these requisi- 
tions. (We mean of course scrofula in relation to cutaneous 
affections, not the type, glandular scrofula, which often has 
nothing to do with them.) Undoubtedly numerous instances 
exist, as I have had an opportunity of observing at St. Louis, 
where M. Bazin's descriptions are strikingly verified. But 
niunerous exceptions exist also. Patients will suffer for years 
from rheumatism, even in its gravest forms, and then exhibit 
an eruption belonging to the first period of arthritis — a circiun- 
stance as embarrassing to the theory as if a gummy tumor should 
be followed, instead of preceded, by a chancre ! Others develop 
so called constitutional affections, after a lifetime of perfect 
health, and I have observed that whenever M. Bazin has to do 
with a remarkably robust patient, who seems to have never 
exhibited a morbid symptom, he generally ranks him under the 
head of arthritis. Again, rheumatism is as frequent among thin, 
weakly people, who from their appearance ought to belong ex- 
clusively to the domain of Dartre, as to the constipated, obese 
individuals whom M. Bazin considers to be alone entitled to its 
afflictions. In this particular, the theory seems affected rather 



Letters to the Medical Record 123 

by old prejudices than by modern ideas. Again, without being 
so exigent as to demand that every patient should present the 
entire cortege of symptoms proper to his disease, we are at least 
entitled to expect the presence of a certain number, upon which 
to establish a diagnosis. Yet M. Bazin will sometimes claim an 
arthritis from the fact that the patient's father was subject to 
sick headaches ; or a dartric because the patient has a bad temper, 
and siiffers neither from haemorrhoids nor constipation; or a 
scrofula, because the skin is white and the temperament lym- 
phatic. In a word, M. Bazin, like all systemizers, being pos- 
sessed of a vivid imagination, and a despotic resolve to subdue all 
facts to his system, refuses to admit that any diseases, with the 
exception of certain exotics, and the parasitic class, can exist 
except as dependencies of one of his four great classes, and conse- 
quently strains his theory, which, if left in its propqr place, would 
be infinitely stronger and more valuable. For, having made all 
these deductions, and having changed the too absolute word, 
disease, into the more usual and acceptable term, diathesis (to 
which M. Bazin gives a forced and arbitrary signification), 
there remains an acute and suggestive generalization — wliich, as 
we shall presently see, affords much practical assistance in the 
comprehension, diagnosis, and treatment of diseases of the skin. 
M. Bazin has not condescended to support his views by statistics, 
but the suggestion might usefully set other people to work, to 
search for confirmation or condemnation of the theory. An 
inquirer, who admits that cutaneous affections may be either 
accidental or constitutional, will be less embarrassed in the 
establishment of constitutional influences, than if obliged mat gre 
hon gre, to drag every eruption under such influence; and the 
relations between rhetmiatic and cutaneous diseases may be more 
clearly discerned, and the dartric diathesis, admitted in France 
from time immemorial, more precisely determined, by the obser- 
ver who was not self-compelled to prove a regular evolution of a 
disease where facts only warranted the irregular connection of 
affections — rooted, not in a malady that had possessed the body, 
but in the innate tendencies of the body's tissues and component 
parts. 

In my next letter I will describe the objective diagnosis, 
made out in obedience to M. Bazin's theory, but capable of appli- 
cation even by those who only admit this theory with modi- 



124 Mary Putnam Jacobi 

fications, and this will tend naturally to a brief notice of the 
therapeutics of St. Louis. P. C. M. 

Paris, Aug. 21. 

The Pathology, Diagnosis, and Treatment of Skin Diseases. 

To the Editor of the Medical Record. 

Sir: — The most remarkable instance of the application of 
Bazin's theory in the diagnosis of cutaneous affections is afforded 
by eczema. According to Hardy, this is always dartrans, and 
always — in its chronic forms at least — to be treated by arsenic. 
For Devergie it is a constitutional disease, belonging to no partic- 
ular diathesis, but expressing a depuratory effort of nature, and 
consequently must not be cured, especially in children. Cazen- 
ave pooh-poohs this ideal, as in fact do almost all the other 
physicians, and declares eczema to be an accidental affection, 
whose principal characteristic is expressed in saying that it is a 
lesion of the sudoriparous glands. But M. Bazin divides eczema- 
tous affections into three great classes, belonging to scrofula, 
arthritis, and dartre. Syphilis is represented by vesiculous erup- 
tion, or false eczema. Each affection requires a different treat- 
ment. 

Urticaria, as a manifestation of dartre, is rather pale, and 
occurs under the influence of moral emotions. The arthritic 
variety is deep red, and occasioned by cold and gastric disturb- 
ance. It frequently complicates rheumatism, springing as it does 
from the same diathesis. The same distinctions may be made 
for acute pityriasis, as when arthritic complicates rheumatism, 
when herpetic is accompanied by sick headaches, and determined 
by moral emotions. 

In arthritic herpes is noticeable the inequality of the vesicles, 
already mentioned as a characteristic of eczema. M. Bazin 
adds — but very inappropriately — the peculiarity of occupying 
uncovered parts of the skin. He thus passes over the well- 
known fact that herpes labialis is an extremely frequent compli- 
cation of fevers (other than typhoid), and thus may be found 
on individuals of all constitutions. The herpes of children is 
certainly much more frequently under the influence of dartre 
or scrofula than of arthritis, which rarely manifests itself at an 
early age. 



Letters to the Medical Record 125 

Herpes circinatus is regarded by all the St. Louis physicians, 
with the exception of Cazenave, as a parasitic disease, originating 
in a cryptogam, identical with that producing herpes tonsurans 
of the hairy scalp, and sycosis of the beard. The cryptogam is 
named tricophyton, and M. Hardy classes these three diseases 
together as one, tricophyte.^ 

In herpes zoster, same distinctions in regard to the vesicles 
and antecedents; besides, the pains in arthritic zona are burning, 
deep-seated, muscular, and often disappear with the appearance 
of the eruption. In herpetic zona (that is, under the influence of 
the dartre) , the pain is lancinating, neuralgic, and generally lasts 
after the eruption has disappeared. 

In herpetic chronic pemphigus, the bullae contain a trans- 
parent citrine colored fluid, are isolated, and equal in size. In 
the arthritic form, the bullas are sero-purulent, unequal, and 
united in large erysipelatous patches. But the cachexia of 
pemphigus is the type of what M. Bazin calls the cachexia of 
dartre, arrived at its ultimate term, and this is true, however the 
debut may be characterized by slight differences. Acute pemph- 
igus, according to Hardy, is merely an accidental erythematous 
eruption, the bullas being quite secondary to the erythematous 
patches upon which they appear, like the phlyctenae in erysipelas. 

A curious case of this affection entered M. Hardy's ward the 
other day. The patient was a man just recovering from an attack 
of lead colic, and had been similarly affected with pemphigus at 
the same period of a previous convalescence from the same disease. 
On admission, he was as red from head to foot as a boiled lobster. 
The fiery patches were not absolutely coalescent, but so nearly so 
that the effect was almost as vivid. Upon the greater number the 
epiderm was elevated in bullae of different sizes. A slight febrile 
movement accompanied the eruption. It was treated like an erup- 
tive fever, let alone, and in a week had almost entirely disappeared, 
leaving brown stains in the place of the patches, that in their turn 
faded rapidly. The affection was therefore essentially distinguished 
from real pemphigus, by expending itself in a single eruption, 
whereas the more formidable disease is noted for the desperate 

' Excuse me if I have mentioned the above idea somewhat dogmatically, 
as if on the supposition that it was entirely unknown at home. But Wilson 
does not mention this theory, and Cazenave disputes it, and as their works 
are the best known in America, I have ventured to be somewhat explicit. 



126 Mary Putnam Jacobi 

tenacity with which fresh crops of bullae continue to appear. M. 
Bazin has a little pet variety of chronic pemphigus — invented by 
himself — and entitled, Hydroa with little bullae. This pretty 
name is applied to a variety almost as chronic as the ordinary 
form, but affording infinitely greater chance for cure. In fact, 
whenever a patient affected with pemphigus gets well, M. Bazin 
calls his malady Hydroa. But the objective feature is the small 
size of the bullae, some of which are not larger than vesicles. 
They appear successively, but only one or two at a time, and are 
covered by very thin crusts. The general health of the patient 
does not suffer the deterioration so remarkable in ordinary chronic 
pemphigus. 

Bazin professes to distinguish psoriasis, lichen and prurigo 
into arthritic and herpetic varieties, but the line is not very well 
defined. He observes that the old herpetic affections are always 
symmetrical, the arthritic almost always irregular, and not 
extending in large confluent patches. Certain horse-shoe and 
circular forms of psoriasis, with a shining coppery hue to the 
skin, instead of the raw ham look of the non-specific variety — 
belong to the cutaneous manifestations of syphilis. The diagno- 
sis is evidently of the utmost importance. Besides these 
affections, containing varieties that belong either to anthritis or 
dartre, are certain others, peculiar to one of these constitutional 
diseases. Erythema nodosum, and papular erythema, are both 
arthritic, according to M. Bazin. So also, St. Anthony's fire, or 
couperose, which he carefully distinguishes from the acne rosacea, 
of which it is a frequent complication. But the pustules belong 
exclusively to the acne; the couperose is constituted by dila- 
tations of the cutaneous capillaries. Acne is always either 
arthritic, or scrofulous, or syphilitic, never herpetic. The 
scrofulous acne develops on the face; the arthritic affection (ex- 
cept the indurated form, which is facial and distinguished from 
scrofula, principally by the antecedents, &c.), appears on the 
back and shoulders ; syphilitic acne is disseminated all over the 
body, and noticeable by the characteristic color of the areola, 
and the fine epidermic scales that remain after desiccation of the 
pustules. M. Bazin insists upon this latter sign, and in his clinic 
mentions cases where its absence has served to correct diagnoses 
of syphilis obstinately applied to young persons whose character 
was above reproach. Mentagra may be arthritic or scrofulous 



Letters to the Medical Record 127 

(scrofulous sycosis), but is not herpetic. The arthritic eruption 
consists of pustules, seated on indurated tubercles, which occupy 
nearly the entire thickness of the derm. The eruption is in cir- 
cumscribed patches occupying the beard on the chin, cheeks, or 
naso-labial sillon. The crusts are thin, brown, and broken. In 
scrofulous sycosis, the crusts are yellow, thick and moist, the lips 
are swollen, and the face generally occupied by acne indurata. 
The tubercles are more superficial. 

Syphilitic acne of the beard, which closely resembles the 
mentagra, is still more profound than the arthritic variety; the 
sub-cutaneous cellular tissue is inflamed and indurated. Finally, 
parasitic sycosis, constituted by the same cryptogamic vege- 
tation as produces herpes tonsurans (the tricophj^ton), is notice- 
able for the alteration of the hairs, which become gray and lustre- 
less in color, broken irregularly, and covered over the roots 
with a fine gray powder. On the other hand, nonspecific roseola 
is always considered as a manifestation of dartre ; one of its early 
symptoms, as papular erythema of arthritis. A certain form 
of impetigo, which M. Bazin calls melitagra, is ranked as herpetic, 
and distinguished from scrofulous impetigo — which occupies 
the head, and appears in large confluent patches — by appearing 
symmetrically on the trunk and limbs, in psydracious pustules 
more or less isolated. 

M. Hardy calls impetigo simply the second stage of eczema, 
of which pityriasis is the third, sometimes also the initial period. 

Finally (for M. Bazin's dissertations on syphilis do not greatly 
differ from those of the rest of the world, and may be left out of 
the question), the great class of scrofulides, divided into benign 
and malignant, occupy the third place in the category of affec- 
tions dependent on constitutional disease — the first, perhaps, in 
importance. It is unnecessary to repeat the symptoms of 
general scrofula, recognized by everybody. M. Bazin errs, 
perhaps, in absorbing into scrofula the lymphatic temperament, 
which, though tending towards scrofula, is distinct from it. As 
symptoms of the first period of scrofula, he reckons the benign 
scrofulous eruptions, classed as exsudative, erythematous, and 
papular, and distinguished from the malignant scrofuHdes by 
leaving no mark or cicatrice. In the first class (exsudative), 
are red gum, eczema, impetigo, and acne sebacea. The char- 
acters distinguishing eczema and impetigo have been mentioned 



128 Mary Putnam Jacobi 



above. All forms of sebaceous acne, whether fluid or concrete, 
are recognized as scrofulous. An interesting case of this trouble- 
some affection was admitted to M. Bazin's ward a little while 
ago. A girl of sixteen, florid and stout, without, however, any 
appearance of scrofula elsewhere, or any derangement of health, 
had been unsuccessfully treated for a year in the attempt to 
remove a patch of concrete sebaceous matter, about three 
centimetres long, situated just above the right eyebrow. If this 
were scraped away it immediately reproduced itself, and con- 
stituted a disagreeable deformity, being a thick, yellow, unctuous 
mass, clinging like a plaster to the forehead. Treatment by 
cod-liver oil and daily alkaline baths, removed the patch en- 
tirely, but the patient declared, from former experience, that it 
will return as soon as the treatment was interrupted. She is still 
at the hospital. 

The papular scrofulides are somewhat discutable. Strophu- 
lus is certainly often an accidental affection. Prurigo mitis, with 
large papules, and only a supportable degree of itching, is con- 
sidered scrofulous, while prurigo ferox always belongs to dartre. 
Erythema papulatum can be distinguished by no objective char- 
acters from arthritic erythema. I have mentioned above that 
facial acne was always scrofulous, that is, the varieties simplex 
and punctata, and occurring in young persons. 

Among erythematous scrofulides M. Bazin counts chil- 
blains; especially those accompanied by deep-seated chronic 
inflammation of the subcutaneous tissue, — ^locality affected in 
preference by the scrofulides. 

The following are the characters common to all the benign 
scrofulides: — Tenacity, persistence in the same place (in opposi- 
tion to dartre, so noticeable for its mobility) ; debut by the head, 
gradual extension to the ears, face, and body; inflammatory proc- 
ess secreting, suppurating or hypertrophic : participation of the 
lymphatic glands, and subcutaneous cellular tissue; absence of 
pain or of intense itching. This latter circumstance is due to the 
deep seat of the inflammation. If it chance to be superficial 
itching becomes quite intense. 

The malignant scrofulides (which, according to Cazenave, are 
all manifestations of hereditary syphilis) are remarkable for their 
extension to the deep layers of subcutaneous tissue, for their well- 
defined limits, and persistence in one place, for the absence of all 



Letters to the Medical Record 129 

pain or itching, and for a strong tendency to relapse after cure. 
These eruptions are divided into three classes : ulcero-crustaceous, 
tuberculous, and erythematous. The crustaceous scrofulide 
contains two important varieties, inflammatory-ulcerating, and 
ulcerating with fibro-plastic formations. The first commences 
with tubercles or pustules simply inflammatory, which degener- 
ate into ulcers, that destroy surrounding soft parts, but are 
arrested by the bones. These ulcers cover themselves with 
thick, green crusts, imbedded in the skin, and formed of super- 
posed and concentric layers. Impetigo rodens and rupia are 
here included. After the crusts have fallen, and the ulcers 
healed, there remain white, irregular cicatrices, retracting the 
tissues like those of a burn, and adherent to the bones. In the 
second variety, the tubercles are fibro-plastic, caused by a prolif- 
eration of the cellular tissue, and the ulcers attack the bones 
as well as the soft parts. It is to this variety that M. Bazin 
especially applies the name of lupus vorax, which is considered an 
independent disease by some other dermatologists. He admits 
the title also in the second class, or tuberculous scrofulides. The 
primitive element is in this case the same as in the other, an 
inflammatory or fibro-plastic tubercle, but it remains stationary, 
without ulcerating on the surface. Curiously enough, however, 
the cicatrices are produced precisely as in the case of open ulcers, 
new fibrous tissue being called upon to fill up the place left vacant 
by the subcutaneous destruction of cellular tissue. Cure is only 
obtained at the expense of such cicatrices. 

The same is true of the third class, erythematous scrofulides. 
These appear as a circumscribed patch of erythema, at first 
seeming to be as innocent as the ordinary ephemeral eruptions. 
But it presently reveals its real nature by its long persistence, its 
dull, pale red color, the pasty suboedematous feeling on pressure 
of the subcutaneous tissue, the absence of all burning, itching, 
pain or fever — finally, the appearance of a white irregular cicatrix 
in the centre of the patch, which gradually extends to the 
circumference. 

Among erythematous scrofulides M. Bazin also includes the 
singular affection described by Devergie as Herpes cretacea. In 
the case quoted by this latter writer, and which was, according 
to him, mistaken for an erythematous scrofulide, the disease 
began by an intense redness of the end of the nose, which persisted 



130 Mary Putnam Jacob! 

with great tenacity; then the surface became furrowed, and 
from the furrows oozed a yellowish secretion, which hardened 
into thick, yellowish, prominent scales. The form of the patch 
was round, and it extended by new rings at the circumference. 

Malignant scrofulides are distinguished from cancer, by the 
edges of the ulcers, which are undermined, instead of prominent, 
bosselated and indurated; by the bottom, which does not present 
the hard, fleshy granulations of cancer ; by the debut with several 
tubercles grouped together, instead of a single one, and by the 
complete absence of pain. 

The diagnosis with syphilis is often much more difficult, since 
the eruptions in both diseases are painless, indolent, chronic, and 
composed of similar elements. But the syphilides are less chronic 
than the scrofulides ; they date by months, but the latter by years. 
This is especially true of the erythematous scrofulide; a case in M. 
Hardy's ward now, has lasted ten years. In fact, there seems to 
be hardly any tendency to spontaneous cure. 

Again : all forms of syphilides, ulcers, tubercles, or crusts, are 
surrounded by the characteristic coppery areola, and the tuber- 
cles are an obscure livid red. In the scrofulides there is fre- 
quently a bluish areola, and the tubercles are semi-transparent. 
Syphilitic crusts are blackish-green, and with edges detached from 
the skin ; in scrofula, the color is clear green, and the crusts are 
firmly imbedded, often like a watch crystal in its case. 

Exostosis and necrosis accompany syphilis; caries is pro- 
duced by the eating ulcers of scrofula. Syphilitic ulcers are 
round, with characteristic edges, and grayish surface. The 
regular form is especially noticeable in the ulcers arising from 
gummy tumors, and in these the bottom is, in a number of stages, 
formed by successive growths of deep-seated gums. The scrofu- 
lous ulcers are irregular in form, the edges undermined, the 
bottom pale-red. Finally, syphilitic cicatrices are smooth, 
shining; scrofulous cicatrices irregular, and formed by the irradi- 
ation of innumerable retracting bands. 

Scrofulous eruptions are much more frequent on the face; 
syphilitic affect the limbs, especially the lower ones; but, as is 
well known, often attack the face also, where they possess 
favorite localities. 

A few words about the therapeutics of St. Louis, M. Bazin's 
treatment is in the main ranged under three heads: cod-liver oil, 



Letters to the Medical Record 131 

iodide of iron, and sulphur baths for scrofulides, malignant or 
benign: alkalies, taken internally, and also in baths for the 
arthritides; arsenic internally, and saline baths for the herpetides. 
He declares sulphur to be positively injurious to the dartre, for 
which it has long been the popular remedy, and believes that its 
reputation is based on cures of scrofulides mistaken for herpetic 
affections. The use of alkalies, especially bi-carbonate of soda, for 
arthritis, seems to have been suggested by their employment 
in rheumatism, which the theory supposes to be akin to the 
eruptions in question. But the effect upon the cutaneous affec- 
tions, — especially the influence of Eau de Vichy, — is often very 
remarkable. In other words, I have seen skin diseases, present- 
ing the characters assigned by Bazin to the arthritides, treated 
perseveringly and unsuccessfully by arsenic, while similar cases 
in his wards recovered rapidly on the alkaline treatment. 

The local treatment is pursued with great care, and comprises 
various resources. The actively inflammatory periods of all 
eruptions, as eczema, impetigo, pityriasis rubrum, and acute 
pemphigus, are treated by emollients, powdered with starch, or 
covered with cataplasms. These latter are applied also to indo- 
lent pustulous scrofulides, to remove the crusts. Only in zona 
and rupia, care is taken to preserve the crusts and vesicles intact, 
until the ulcer shall have healed underneath. 

M. Hardy obtains extraordinary success by covering the 
eruption with vulcanized India-rubber. This retains the in- 
sensible perspiration, and keeps the part immersed continually 
in a natural vapor bath, which reduces inflammation, allays 
burning and itching, and removes incrustations in a very short 
time. 

An India-rubber cap is often of signal service in eczema capitis 
with its tormenting irritation. In one case of severe herpetic 
eczema occupying both arms the rubber casing was at first applied 
to one only. In a week the scales had fallen, the secretion dried, 
the fissures to a great extent healed, and the angry redness was 
entirely subdued. The other arm, which only experienced the 
effect of the general treatment (tisane of wild violets and senna, 
acting as a derivative purgative, a favorite remedy with M. 
Hardy in the early treatment of all exsudative eruptions), re- 
mained in precisely the same condition as at first. 

Vapor, cold and sulphur baths, and douches, are of course 



132 Mary Putnam Jacobi 

largely included in the local treatment, but with about the same 
indications as are observed in other places than St. Louis. But 
many forms of disease are treated more boldly on a substitutive 
plan, than is generally the case elsewhere. Acne, for instance 
(which Hardy pronounces an accidental disease), is attacked by 
mercurial ointments and lotions of corrosive sublimate, with or 
without general medication. 

Malignant scrofulides are painted with tinctures of iodine, 
ordinary or caustic, with oil of juniper, or of mahogany nuts. 
The two last remedies seem, in M. Bazin's hands, to exercise a 
real and marked influence over lupus and other scrofuUdes; and I 
have seen the mahogany oil succeed in several extremely severe 
and obstinate cases, that have resisted every other application. 

M. Bazin advocates also creasote, nitric acid, nitrate of mer- 
cury, also perchloride of iron for Lupus vorax. But I have never 
seen him apply either. The iodine does not seem to be so gener- 
ally successful, though it succeeds in some cases. 

The ordinary application for psoriasis is tar ointment. If 
that produces too violent irritation, a pomade of oxide of zinc 
and camphor, or calomel ointments are substituted. To calm 
the torments of lichen and prurigo, ointments of cyanide of 
potassium, 5-10 centig. to 30 grms. of lard, are employed. Also 
ointments containing i grm. of calomel and 2-3 grms. of tannin 
to the 30 grms. Similar applications are made in chronic eczema, 
which is also treated by the bichloride of mercury in ointments 
and lotions, by M. Hardy. 

For pemphigus foliacea, and cachectic or syphilitic ecthyma, 
much reliance is placed upon a mixture of quinquina and powder 
of worm-eaten wood, as a palliative. 

Bazin pronounces decidedly upon the appropriateness of 
curing eruptive affections of children. Cazenave admits the 
same advisability, though he recommends precautions. Both 
observe that the affections left to themselves, frequently tend 
to become inveterate, and assume worse forms; infantile eczema 
degenerating into chronic lichen, benign scrofulides becoming 
malignant, &c. As long as the patient remains under the in- 
fluence of the constitutional disease, a relapse of the affection 
or of its equivalent, is to be expected as a matter of course, and the 
physician must be prepared to combat it afresh, until the dis- 
ease be exhausted. But the dangers of repercussion (upon which 



Letters to the Medical Record 133 

D^vergie still insists), have been greatly exaggerated, and are 
chiefly based upon the fact, that the intercurrence of an acute 
disease causes the temporary cessation of the cutaneous affection, 
even though that be parasitic, as scabies. This (the parasitic 
also) returns after convalescence from the intercurrent malady. 
The true interpretation of the relation between the internal 
and external affections has, therefore, according to the St. Louis 
physicians, been precisely inverted. P. C. M. 

Paris, Oct., 1868. 

Gonorrhoeal Rheumatism. 

To the Editor of the Medical Record. 

Sir — ^According to Follet, gonorrhoeal rheumatism was 
described for the first time by Swediaur in a medical journal 
published at London in 178 1, It was subsequently admitted, 
though with some indecision, by Hunter. The French physician 
above-mentioned, who fully believes in the distinct existence of 
this form of arthritic disease, describes it as follows : 

It occurs in about i case in 35 of urethral gonorrhoea, upon 
which it depends directly, as eSect upon cause, and with patients 
who have never before suffered from rheumatism. Relapse of the 
urethral affection determines a similar relapse of the articular 
with fatal regularity. It is rare among women, probably because 
with them the gonorrhoeal flux is more often located in the vagina 
than the urethra. 

It declares itself at the moment that this flux is most abun- 
dant, and the latter generally diminishes with the progress of the 
rheumatism, but rarely ceases altogether until that has dis- 
appeared. There is, therefore, no appearance of a metastasis, 
properly so-called. Debut of the arthritis is sometimes brusque 
— by articular pain almost always limited to one joint, especially 
the knee, and after that, in point of frequency, the shoulder. At 
other times chills, fevers, and gastric disturbance precede the 
arthritis, but these general sjntnptoms are always much less 
pronounced than in ordinary acute rheumatism. The affection 
of the joints may, however, extend from the one first invaded, but 
the secondary inflammations are generally less intense, and often 
fail altogether. 

Follet confirms the interesting observation already made by 



134 Mary Putnam JacobI 

Hunter, that the blood presents no inflammatory clot, and in that 
respect resembles the blood in chronic rheumatism. Cardiac 
symptoms are rare, and of little gravity. The articular pains 
consist at first of a sensation of stiffness and numbness, but 
presently become excessively severe, contusive, boring, lancinat- 
ing. Swediaur describes them as frightful. According to Vel- 
peau, however, they are sometimes absent altogether. The 
swelling of the joint is considerable; the inflammation rarely 
mobile, retaining its original place with great tenacity, even when 
it has extended its influence to other articulations. 

The ordinary duration of this form of rheumatism is 6 to 8 
weeks. Follet admits resolution as habitual, and ankylosis as a 
rare termination, but other physicians consider the frequency 
of ankylosis as among the most characteristic symptoms of 
gonorrhoeal rheumatism, and Follet himself notices that the 
synovial is more profoundly attacked than in the ordinary dis- 
ease. This termination was noticeable in the case of a young girl 
recently a patient in M. Gosselin's wards, and that I had an 
opportunity of observing. She entered the hospital for a slightly 
pyretic rheumatism, apparently generalized, but bearing most 
heavily upon the left knee. The case was at first considered an 
ordinary one, but in a day or two the general symptoms had 
disappeared, and all the articulations were disengaged, except 
the knee, where the intensity of the inflammation continued to 
increase during three or four weeks. The complete defervescence, 
the persistence of great pain and swelling after the redness had 
disappeared, caused M. Gosselin to fear the formation of a white 
swelling {tumeur blanche), although neither the patient's ap- 
pearance nor antecedents indicated scrofula. The limb was 
placed in an immobilizing wire gutter, and the inflammation 
constantly combated by emollients. The inflammation finally 
subsided about three weeks later, but the joint was perfectly 
ankylosed in extension. Examination then made for the first 
time discovered a purulent oozing from the urethra, and the 
patient acknowledged the previous existence of blennorrhagic 
accidents. 

This case is the more interesting because many persons have 
denied the existence of blennorrhagic rheumatism in female 
patients. The reason above quoted from Follet, and the greater 
difficulty of exploration, and more frequent attempts at conceal- 



Letters to the Medical Record 135 

ment on the part of the women, may serve to explain this 
difference. 

M. Foumier observes that he had only been able to find four 
observations of such coincidence, related by authors, of which two 
were by Cullerier and two by Richet, but he himself has recently 
come across four others all at once, and describes two at length. 
In the first case the pain commenced at the hip, then successively 
invaded the knee and the ring-finger. The wrist was somewhat 
swollen, but movements intact. The patient was pregnant, and 
examination (notwithstanding denial) discovered greenish pus at 
the urinary meatus. The rheumatism gradually invaded the 
extensor tendons of the hand, and the pain remained atrocious for 
three weeks. As it diminished, the gonorrhoeal flux diminished 
also, and changed color, but the metacarpophalangeal articulation 
of the ring-finger ankylosed completely. 

In the second case the rhetmiatism occupied exclusively the 
tendons of the pes anserinus at the right knee, and of the femoral 
biceps at the left. The articulations were healthy, but move- 
ment extremely painful. Complete absence of general symptoms 
and of rheumatismal antecedents. Coincidence of a pregnancy 
of several months, and of well-marked urethral gonorrhoea. 

I will make a last quotation of an observation related by M. 
Peter, and which formed the starting-point for the long discussion 
at the Academy. The patient entered the hospital with a bi- 
lateral sciatica, and pain upon pressure on the spinal apophyses 
of the umbar and cervical vertebras. Cutaneous sensibility was 
deadened in the legs, and especially the feet, which were be- 
numbed at the soles. The gait was enfeebled and limping. Fin- 
ally, the circular pain around the waist helped to decide the 
diagnosis of marked disease of the spinal cord. 

It was subsequently discovered that the patient was also 
suffering from his third attack of gonorrhoea, dating from three 
months previous. The sciatica was of ten days' duration, and the 
douleur en ceinture three. 

Three-inch scarifying cups were applied to the lumbar 
region, and copaiba and cubebs administered internally. The 
pain was immediately diminished the next morning, but the 
feebleness remained the same. Vapor douches were ordered 
after the second day. The cupping was repeated three times 
in the course of thirteen days, and the pain and gonorrhoea 



136 Mary Putnam Jacobi 

diminished together, and markedly, on the fourteenth day, 
occurred a pain in the temporo-maxillary articulation, speedily 
relieved by laudanized cotton wool. On the 23d day, pain in the 
right knee, also relieved in the same manner. At this period the 
vapor douches were replaced by sulphurous, and these triumphed 
over the feebleness and numbness remaining in the limbs. A 
month from the date of admission the patient left entirely well, 
thus happily exchanging the original diagnosis for that of a gon- 
orrhceal rheumatism. Many other similar cases have been placed 
on record, of which I will only mention that inserted in the 
Archives of Medicine by Fereol. A gonorrhoea of five months' 
standing was complicated by a mono-articular arthritis of the left 
wrist, and, a month later, by an oedematous phlegmon of the left 
submaxillary region, whose point of departure existed in the 
inflammation of a lymphatic ganglion at the angle of the jaw. In 
three days this phlegmon had extended from the cheek-bone to 
the clavicle, but without comprising the parotid. It presented a 
lardaceous, almost woody hardness, but was neither vasculated 
nor fluctuating. The redness was bright, the pain exquisite. 
The phlegmon was punctured with the trocar, giving issue to a 
quantity of pale fluid blood, mingled with serosity. and the oper- 
ation was followed by complete cure. 

The physicians who debate on the question actually diminish 
the proportion of coincidences between gonorroeha and rheu- 
matism from I in 35 (as stated by Follet), to i in 62. 

Upon these coincidences what opinion is to be formed ? 

In the first place, the necessity for any peculiar opinion may 
be altogether denied, on the ground that the coincidence is merely 
casual, a gonorrhoeal patient catching rheumatism like any other 
when exposed to accidents of cold, etc. Against this idea are 
opposed the arguments: ist, That in patients liable to this 
duplicate affection, relapse of either of its branches is almost 
invariably attended by the appearance of the other. Its com- 
parative rarity therefore, should not count against its reality, 
more than in the case of any other disease. 2d, That the rheu- 
matism which coincides with gonorrhoea possesses peculiar char- 
acteristics, sufficing to distinguish it essentially from ordinary 
articular inflammation. The first argument is sufficiently stated; 
the second deserves some consideration. 

Reference to the description given at the beginning of this 



Letters to the Medical Record 137 

article will show that the arthritis in question is that long known 
as mono-articular rheumatism, and recognized as notably differ- 
ent from the generalized disease, either acute or chronic. Its 
entire obstinacy to the quinine treatment is not the least interest- 
ing distinction that can be made in its character. The less 
frequent and intimate connection with cardiac disease is another 
important circumstance, though by no means always to be 
relied upon. I saw a case last summer at La Charite, of mono- 
arthritis of the left tibio-tarsal articulation, accompanied by a 
pericarditis that proved fatal. Still, in a general way, these con- 
siderations, and those already mentioned, really suffice to estab- 
lish a specific separation of this disease from ordinary rheu- 
matism. It now remains to be decided, whether this species 
should itself be divided into simple mono-articular rheumatism 
and that essentially connected, either as cause or effect, with 
gonorrhoea. 

As I have already reached my limits, I defer this question 
to my next letter. P. C. M. 

Association of Rheumatism and Chorea. 

To the Editor of the Medical Record. 

Sir — As I have had occasion already to notice, rheumatism, 
in the estimation of European physicians tends continually to 
enlarge its sphere of influence, and to take its place as a widely 
ramifying constitutional disease by the side of scrofula and 
syphilis. Under the name of arthritis, M. Bazin attacks rheu- 
matism of the skin as endopericarditis ; M. Bouilland pursues 
rheumatism of the heart, and Roger, See, Botrel, Axenfeld, 
Trousseau, and others, detect its malignant intervention in the 
production of neuroses, and especially the chorea of childhood. 
The connection between rheumatism and chorea had already been 
signalized by StoU and Sauvages; by Bouteille, who first distin- 
guished chorea from the epidemic St. Vitus' dance, with which it 
had been confounded by Sydenham; and in England Copland, 
Bright, Abercrombie, and Begbie, had insisted with more or less 
emphasis on the common parentage of the two diseases. This 
view was, however, deliberately defended in extenso for the first 
time, in 1850, by Botrel, in an inaugural thesis, and by S^e, in 
a memoir subsequently recompensed by the Academy. Trous- 



138 Mary Putnam Jacobi 

seau, in his Clinique M^dicale, adopts the views of Professor S^e, 
whom he accuses, nevertheless, of a certain exaggeration; and 
Roger, physician at the children's hospital, in a series of articles 
recently published in the Archives of Medicine, furnishes a 
number of observations tending to prove that in children rheu- 
matism and chorea accompany and alternate with one an- 
other, as frequently as rheumatism and endo pericarditis in 
adults. 

Rheumatism can no longer be defined as a mode of inflam- 
mation characterized by its predilection for serous membranes. 
No tissue of the economy — fibrous, muscular, mucous, nervous — 
is exempt from its ravages. It is pre-eminently a general, con- 
stitutional disease, whose affections or manifestations may be 
classed in three groups — synovial, visceral, and nervous. Neither 
one of these groups is a cause of the others, but all are equally 
rooted in the common rheumatic vice. A patient does not have 
endocarditis, or rheumatic pleurisy, or meningitis, or chorea, as a 
consequence of his articular inflammation, or as a result of its 
metastasis, but the internal, as well as the external affection 
occurs as another symptom or manifestation of the general rheu- 
matism that has possessed itself of his entire organism. The 
visceral or nervous affection may precede, or accompany, or 
follow the articular, just as the symptoms of pain may precede, 
or accompany, or follow the symptom of swelling in rheumatism 
of the joints. But in neither case is it relative of cause and effect 
that exist between the elements of the double phenomena, 
but a common filiation in a general condition that embraces them 
both. 

M. S6e remarks that there is hardly an affection of the nervous 
system that may not declare itself under the influence of rheu- 
matism — tetanus, delirium, muscular contractions, apoplexy, 
meningitis, and especially chorea, which occupies us for the 
moment. The professor ranks in three categories the cases in 
which the association of rheumatism and chorea has been 
observed. 

1st. Categ. chorea, preceded by rheumatism j ^^^-^ pains i\o 

2d. Chorea accompanying rheumatism -I ^^^^^ pains. ) 8 

3d. Chorea accompanying external or internal i 30, of which J 
rheumatism \ 7 were fatal J 



Letters to the Medical Record 139 

Finally, M. See ranks in a fourth category a certain number 
of cases (17), the only ones open to doubt, where the chorea was 
accompanied by a visceral rheumatism exclusively. The total 
is then 140. 

M. Roger, for his part, undertakes to furnish cases: ist. 
In which the chorea develops simultaneously with the rheu- 
matism, or so soon after the latter affection, that the common 
filiation is apparent at once, 2d. Where the rheumatism mani- 
festly engenders the chorea, which in its turn occasions an attack 
of rheumatism, and where this alternate generation attests the 
parentage of the two diseases. 

The first class contains three subdivisions. (A.) The chorea 
declares itself during the convalescence, or shortly after the 
presumed cure of a rheumatism. (B.) The chorea complicates 
the rheumatism during its period of greatest intensity. (C.) The 
rheumatism and chorea make their first appearance simultaneously. 

The first case is the most common, the articular inflammation 
seeming to transform itself into chorea with most facility during 
its period of decline. It might be said that the general rheu- 
matism, having expended its violence in one direction, and 
forced by the strength of nature or art to beat a retreat, aimed a 
Parthian dart as it took to flight. There is, therefore, or should 
be, after the apparent establishment of complete convalescence, 
a moment of extreme anxiety for the physician, of which the 
patient is happily unconscious. The fever has fallen, or even dis- 
appeared; the swelling, pain, and heat have been exorcised at 
the articulations; but there remains an indefinable something, 
sufficient to indicate that the child is still menaced by his insid- 
ious enemy. It is at this moment that the choreic movements 
generally make their appearance. 

Obs. 1ST. Polyarticular, subacute rheumatism in a child of 
II years. 15 days after recovery a severe generalized chorea. 
A scarlatina complicated the neurosis, and during the fever the 
muscular disorder was aggravated, but diminished rapidly and 
pari passu with the exanthem. An arsenical treatment, 2.10, 
milligrammes a day, had been instituted for the chorea, but was 
interrupted by the scarlatina. The heart remained unaffected. 

Obs. 2D. Extremely slight attack of articular rheumatism in 
a child of 5 years old; a few days after recovery occurred a severe 
generalized chorea. During the interval, the child had been 



140 Mary Putnam Jacobi 

frightened by witnessing an epileptic convulsion, but the chorea 
was not developed until four days later, and could not, therefore, 
be referred to the moral emotion, which always produces its effect 
immediately, when it exercises any influence at all. 

Obs. 3D. The child of rheumatic parents suffers a slight 
attack of febrile articular rheumatism of the lower limbs, which 
only lasts a week. Eight days after recovery chorea commenced 
violently, manifesting itself by grimaces, movements of hands 
and feet, agitation in the gait, difficulty of speech, diminution of 
sensibility and intelligence. No fever, heart normal. In this 
case, as in many others, the intensity of the chorea was in remark- 
able contrast with the mildness of the rheumatism. 

Obs. 4TH. Acute polyarticular rheumatism, with pleurisy, 
in a girl of 14. Menstruation established for eleven months. 
Rheumatism severe, followed by a chorea of medium intensity. 

Obs. 5TH. Rheumatism with pericarditis in a child of 12. 
During the decline of the rheumatic pains, a slight attack of 
chorea, which disappeared in three weeks. Palpitations and 
rubbing sound at the prascordium persisted. 

The chorea, observes M. Roger, was not dependent upon the 
pericarditis but upon the rheumatic vice, which, having affected 
two different parts of the economy, finally attacked a third. 

Obs. 6th. Acute articular rheumatism; during the decline 
severe chorea; recovery. A year later chorea and slight endo- 
carditis. Cure of both affections. 

(b.) This Class Contains Observations of Rheumatism, Accom- 
panied by Chorea during its period of intensity. 

Obs. 7TH. Endopericarditis, with such abundant effusion 
that the life of the patient was seriously compromised. The 
following year a long attack of subacute rheumatism, accomp- 
anied by a slight chorea, which disappeared gradually at the end 
of a month. Neither rheumatism nor chorea returned, and the 
heart disease was notably ameliorated. 

This case is remarkable, as showing the intimate connection 
of the three members of the rheumatic trilogy, even when the 
endocarditis, developing itself first and alone, might have been 
considered quite independent of rheumatism. 

Obs. 8th. Polyarticular rheumatism caused by cold, in a 
child of 14. Endocarditis and double pleurisy, nearly simul- 



Letters to the Medical Record 141 

taneous; slight chorea the 15th day, which increases as the 
pleural effusion diminishes. At this moment exacerbation of 
rheumatic pains during several days, and as they diminish, the 
chorea diminishes and disappears. 

In this interesting observation, M. Roger calls attention to 
the multiplicity of the rheumatic accidents, their succession, 
their so-called metastases. First, rheumatic fever, then in- 
flammation of several joints, followed by participation of the 
pericardium. The cardiac phlegmasia diminishes, rheumatism 
resumes its ascendency, manifesting itself in a double pleurisy. 
This in turn yields place to the chorea, which gains ground with 
every inch relinquished by articular and pleural rheumatism. 
Finally, a month later, when the chorea begins to abate, occurs 
a new attack of rheumatism. The most delicate balance seemed 
to be maintained between the articular rhemnatic phenomena, 
and the muscular disorders of the chorea. 

(c.) Observations of Rheumatism Complicated by Chorea from 
the Beginning. 

Obs. 9th. Several attacks of acute articular rheumatism, 
with endocarditis; the last complicated with a slight chorea, 
rapidly cured. 

Obs. loth. Two attacks of articular rheumatism at a year's 
interval, both complicated with chorea and cardiac affection, 
occurring simultaneously. Sometimes the chorea predominated, 
sometimes the articular rheimiatism, until both affections ceased 
altogether, leaving an endopericarditis as a permanent heritage 
to the economy. 

Obs. nth. Exceedingly slight attack of rheumatism, com- 
plicated by severe chorea: pulmonary congestion, followed by 
endocarditis. After the amelioration of the latter affection 
occurs a relapse of the rheumatism, that continues to be slight. 
The chorea persisted in its intensity throughout the whole, 
accompanied by a diminution of the intelligence, but was finally 
cured, while the heart disease remained permanent. 

(d.) Observations of Coincidence and Alternation of Rheumatism 
and Chorea. 

Obs. 12th. Six attacks of rheumatism and five of chorea, 
coinciding or alternating in less than five years. Hemiplegia at 



142 Mary Putnam Jacobi 

the first relapse of rheumatism, and endocarditis at the 
second. 

The first attack of rheumatism occurred at seven years 
old, and was uncomplicated. Four months later, a second 
attack, complicated with hemiplegia and intense generalized 
chorea. At nine years, a third — rheumatism, this time with 
endocarditis, and a second severe chorea. At ten years, another 
combination of rheumatism and chorea. Finally at twelve, a 
fifth attack of chorea, this time of slight intensity. After this, 
the unhappy patient seemed definitely rid of his rheumatism and 
his chorea, but the organic heart disease persisted. 

The identity between the three affections is apparent in this 
case: the articular inflammation, the chorea, the cardiac phleg- 
masia combine, replace each other, confound themselves with 
one another, having the same origin and the same termination, 
being the triple expression of a unique vice — rheumatism. 

The facts proving an intimate connection between rheu- 
matism and chorea, may be summed up as follows : 

Chorea occurs frequently in children affected with rheu- 
matism ; coincidence of the two affections. 

Frequently rheumatism is closely followed by chorea; relation 
of cause and effect. 

Rheumatism may complicate itself with a chorea, which 
survives the first attack, but presently is accompanied by a re- 
lapse of rheumatism; parentage of the two diseases. 

Rheumatism and chorea may arise simultaneously under 
the influence of cold, march together, the rheumatism cease, 
the muscular ataxy being of more chronic nature, persist, and 
finally, as a band of union between the two, may develop an endo- 
or peri-carditis ; identity of nature. 

Clinical experience proves, not only the frequency of the 
relation between chorea and rheumatism, but almost the con- 
stancy of this relation; and henceforth the description of the 
rheumatism of childhood should include chorea as one of its most 
essential elements. These ideas cannot fail to modify the prog- 
nosis both of chorea and of infantile rheumatism. 

This rheumatic chorea belongs almost exclusively to child- 
hood, and is explained by the extreme excitability of the nervous 
system in children, easily aroused by the influence of the rheu- 
matic vice. 



Letters to the Medical Record 143 

Chorea is most imminent during the decline of rheumatism, 
and as a complication of benign forms of the articular affection, 
often limited to vague, ill-defined pains, frequently called 
"growing pains." And there is a certain opposition between the 
intensity of the two affections, so that severe chorea is more likely 
to accompany a slight attack of rheumatism, and inversely, a 
severe rheimiatism to be complicated by slight choreic move- 
ments. P. C. M. 



Paris, May 6th, 1869. 
Letters on Albuminuria. 

It occasionally happens in the history of scientific research, 
that the original discoverers of new truths are able to immedi- 
ately divine their consequences, and foresee the problems to 
which they will give rise. In this case, the widest subsequent 
ramifications of the subject may be traced back to their germ 
in the propositions of the original investigator, and the various 
doctrines which at different periods have been professed as 
exclusive seem all to have been foreboded by him, and to arise 
merely from some unduly special emphasis which has been laid 
upon one or another of his words. 

The comprehensive moderation with which Dr. Bright 
announced his discovery of renal lesions as existing in that form 
of dropsy which is accompanied by albuminous urine, ^ places him 
unequivocally among those farsighted observers who forestall the 
disputes of posterity by statements that embrace all sides of the 
questions at issue : 

"Organic changes occasionally present themselves in the structure of the 
kidneys which, whether they are to be considered as the cause of the dropsical 
efifusion, or as the consequence of some other disease, cannot be unimportant. 
I have often found the dropsy connected with the secretion of albuminous 
urine more or less coagulable by heat, and in these cases the liver has presented 
no alteration. On the other hand, in the dropsies dependent on liver disease, 
the kidneys have been healthy apd the urine non-coagulable. Whether the 
morbid structure is to be considered as having, in its incipient state given 
rise to an alteration in the secreting power, or whether the organic change 
be the consequence of long-continued morbid action, may admit of doubt. 

"The more probable solution appears to be that the altered action of the 
kidney is the result of various hurtful causes influencing it through the medium 
of the stomach and skin, thus deranging the healthy balance of the circula- 

' Report of Medical Cases, vol. i, 1827. 



144 Mary Putnam Jacobi 

tion or producing an inflammatory state of the kidney itself; that when 
this continues long, the structure of the kidney becomes permanently changed, 
either in accordance with the morbid action, or by a deposit which is its 
consequence, but has no share in that arrangement of the vessels upon which 
the morbid action depends." 

In the first paragraph quoted, Dr. Bright distinctly dis- 
engages a triad of phenomena, of which one had been ignored 
entirely, another misunderstood, and the third exclusively 
associated with a known organic lesion. This triad, renal lesion, 
albuminuria, and dropsy, alone deserve the name of Bright's 
disease, which cannot be lawfully represented by any one of the 
elements taken separately. In the second paragraph he raises 
the important debate between the local and general origin of this 
disease, and the question of priority of the functional derange- 
ment or structural alterations. A collection of twenty-two cases 
follows, whose history and anatomical pathology embrace nearly 
all the forms that have since been observed. Finally, a classi- 
fication of these forms, which are all admitted as equally char- 
acteristic of the disease in question, and the suggestion that these 
variations may possibly represent the progressive stages of an 
affection essentially unique. 

It is certain, therefore, that whoever regards Bright's disease 
exclusively as a local nephritic disorder, or exclusively connected 
with any one renal lesion, or as an incoherent assemblage of 
lesions independent of one another, or as a mere functional 
phenomenon, not only limits the subject, but limits the intention 
of the observer who first introduced the subject to the medical 
world. 

The history of the doctrines concerning albiuninuria may be 
resumed in five periods. The first includes all time previous to 
the eighteenth century, during which dropsy was recognized, 
studied, treated, and even painted, ^ and attributed to a variety 
of causes, especially liver disease, obstruction in the veins, lesion 
of the lymphatics. In the middle of the eighteenth century, 
Cotugno discovered the second element of Bright's triad, the 
albuminuria. The methodical reasoning by which he arrived 
at his discovery is worthy of notice. He had observed that the 
serous effusions in dropsical patients were coagulable by heat, 

' See the horrible picture of Gerard Dow at the Louvre — "La femme hydro- 
pique." 



Letters to the Medical Record 145 

and ascertained that the fluid secreted by the healthy serous 
membranes was not coagulable. He concluded therefore that 
some new substance had been added to the serous secretion by 
the fact of the disease. This was the first step. The second 
consisted in an observation entirely independent of the first, 
namely, that when the quantity of urine passed by the patients 
increased, the dropsical effusion diminished. He inferred that 
the kidneys had exerted themselves to carry off the liquid from 
the serous cavities. To prove the identity between the surplus 
urine and the ascitic fluid, he bethought himself to search in the 
former for the coagulable substance which he had previously 
discovered in the latter. The same test produced the same 
result, the urine coagulated by heat, ergo it had received into its 
current the peccant humor of the disease, for which it constituted 
a valuable channel of derivation.^ 

Those who consider renal lesions as the sole and efficient 
cause of albuminous urine will hasten to criticize Cotugno's 
assumption that the albumen in the urine was derived from that 
in the peritoneal serimi. On the other hand we shall find M. 
Gubler, in a recent essay, ^ citing the resorption of serous effusions 
as a frequent cause of albuminuria. At all events it is certain 
that Cotugno's ingenious reasoning led him the first (according 
to Rayer) to the discovery of albumen in the urine of dropsical 
patients. 

Two-thirds of the triad were now constituted; the third link 
was added by Bright in his first autopsy at Guy's Hospital. The 
patient, John Peacock, had been suddenly attacked with dropsi- 
cal swellings of the entire body, accompanied by fever and 
constant pain in the small of the back. The urine was sanguino- 
lent and albuminous. Death occurred in seven weeks, and at 
the autopsy the liver was found to be healthy, but the surface 
of the kidneys completely granulated, rough, hard, and uneven. 
The cortical substance seemed quite disorganized, but the tubular 
portion was healthy. 

This coincidence between dropsy, albuminuria, and renal 
cortical disease, was confirmed by several subsequent autopsies, 
and these three elements henceforth assumed definite and 
permanent relations with one another, in a newly organized 

' Cotunnius, De ischiade nervosa, pp. 24, 25 (quoted by Rayer). 
^ Diet, des Sciences Medicates, 1865. Art. Albuminurie, Gubler. 



146 Mary Putnam Jacobi 

disease. This is the third period, of which Cotugno's discovery 
constitutes the second in the history of anasarca! albuminuria. 

The enthusiastic ardor with which anatomical researches 
were pursued in the fertile field laid open by Bright — the eclat of 
the school of Rayer and of the lessons of Martin Solon — 
the application of the microscope by Valentin^ — all tended 
to concentrate attention upon the structural alterations of the 
kidney, as the sole and essential cause both of albuminuria and 
of the anasarca which frequently accompanies it. All the 
anatomists confirmed Bright 's original statement — that a 
multiplicity of lesions were discoverable coinciding with albumin- 
uria. The opinions differed, however, concerning the mutual 
relations of these lesions — the German school, after Frerichs, de- 
ciding that they represented progressive stages of a unique mor- 
bid process; the English, nearly unanimous in maintaining their 
independence, or in selecting one or another among the forms as 
alone characteristic of Bright's disease. This is the fourth period. 

Finally arrives the fifth, which has by no means supplanted 
the fourth, but coincides with it, being rather a mode than a 
period of thought Here the investigator refuses to arrest his 
researches at the kidneys, as the essential and sufficient agent 
of albuminuria, but seeks, in the organism at large, the com- 
mon cause of their lesion, and of the passage of albumen in the 
urine. Valentin himself had suggested this extensive search, in 
the very passage in which he describes the first microscopical 
examination of a diseased kidney. "The kidneys are only the 
receptacle of the abnormal urine," he writes, "and the real dis- 
order of secretion must be sought further removed, and in the 
blood." 

A multitude of questions of the highest interest are resumed 
in these two groups of pathogenetic theories. To commence 
with the first group, we will first describe in simple succession 
the different alterations that have been observed in the structure 
of the kidney; afterwards the classifications that have been 
framed of these lesions, from the Report of Bright in 1827, to the 
recent thesis of Cornil, ^ in 1869 ; finally the inferences that may be 
drawn from purely anatomical investigations; clinical histories, 

' Reperlorium fur Anatomie et Physiol. 1837. 

' Cornil, Nephrites albumineuses — These de concours pour I'agregation, 
1869. 



Letters to the Medical Record 147 

and their combination with the facts of pathological anatomy, 
association and causes of symptoms coincident with albuminuria, 
prognosis, general pathogeny of this phenomenon, and the diseases 
in which it occurs, with their treatment, &c. These topics will 
form the subject of other letters. 

The cases described by Bright may be resumed, as he in fact 
resumes them, into five forms, of which three are principal, and 
the other two barely mentioned. In the first case "a state of 
degeneracy exists, which seems to mark little more than a 
simple debility." It is not very clear what is meant by this 
"debility of the kidney," but the description given by Bright 
is readily recognizable, and perhaps covers several distinct forms 
that later are separated by the microscope. The kidney loses its 
firmness, and becomes pale, more or less mottled with yellow, 
externally and internally (in the cortical substance). In what 
appears to be a more advanced stage of the same lesion, are 
found on the surface, white portions, somewhat raised above 
the surface, and upon which ramify starlike vessels. Consider- 
able spaces (the same?) are quite impermeable to injections. 
The tunic adheres closely. The cortex is a uniform yellow color, 
sprinkled with small, opaque, and indistinct yeUow spots. The 
size of the kidneys is not altered. 

This form, says Bright, may be observed in cachexias, even 
unaccompanied by dropsy, as in phthisis, diarrhoea, and ovarian 
timior; urine only slightly coagulable. This seems to correspond 
to the third form described by Rayer.^ The cortical substance 
is smooth and pretty equally colored throughout, being pale 
yellow, or very slightly rose-hued; sometimes the tint is so re- 
markably pale as to resemble an eel's skin. Here and there 
appear points of injected vessels, or brown and slate-colored spots 
seeming to originate in some former sanguinolent effusion. 

At an autopsy performed at La Pitie yesterday, remarkable 
on many accounts, occurred a fine example of this anaemic kidney. 
The patient had succumbed to repeated attacks of haematemesis, 
dependent (as was only clearly proved by the autopsy) upon 
simultaneous cirrhosis of the liver and spleen. ^ The kidneys were 

' Traite des maladies des reins, 1840. 

' The latter organ was 24 centimetres long, and 12 broad, descending 
only two finger-breadths below the false ribs, but pushing up the diaphragm 
as high as the 5th rib and touching the liver behind the stomach. 



148 Mary Putnam Jacobi 

normal in size, flattened, and rather less firm than usual. The 
capsule was removed with remarkable facility, and the surface 
of the organ appeared pale, smooth and polished as marble — 
white, slightly tinged with rose lilac. Here and there appeared 
little scarlet stellated vessels, isolated, or united in small groups. 
On section, the same smoothness and uniformity of color were 
observed throughout the two substances. Their relations to 
each other seemed normal, unless it were that the cortical sub- 
stances were slightly diminished in diameter. 

But besides these unequivocally anaemic kidneys, are others 
whose pallor is explained by a commencement of fatty degener- 
ation. Martin Solon ' describes as the initial stage of the ' ' third 
degree," a condition where the kidneys are but slightly hyper- 
trophied, with surface smooth and polished, and an extremely 
pale yellow hue, like that of the pancreas. Johnson^ repeatedly 
describes the "smooth, mottled, — or waxy uniform yellowish 
white kidney," as in a state of fatty degeneration. ComiP 
observes that in temporary albuminuria, the kidneys, to the 
naked eye, only differ from the normal appearance by a grayish'' 
color, and a certain opacity of their cortical substance; but on 
microscopical examination with low magnifying power, 40-50 
diameters, the convoluted tubes are found sombre and opaque to 
transmitted light, and filled with tumefied epithelial cells. These 
are infiltrated with proteic and fatty granulations, and the in- 
filtration is the cause of the opacity and whitish appearance of the 
cortical tubes. 

There is a third morbid process which may be indicated by 
these appearances described by Bright and Rayer. In the very 
beginning of the amyloid degeneration the kidneys often retain 
their normal size, the capsule is easily removed, the surface is 
extremely polished, and its coloration, as also that of the interior, 
pale, anaemic, slightly yellow in the cortical substance. All parts 
of the renal parenchyma affected with amyloid infiltration are 
impermeable to injections, which therefore dot the surface of the 
kidney with red spots and streaks, contrasting with the pale 
ground. Another important character is the occurrence of the 

^DeV Album iniirie, 1838. ^ Med. Chir. Transactions, 1846-1859. 

3 Loc. cit. 

4 "Coloration grise," — almost the same as our pale yellow, or yellowish 
white. 



Letters to the Medical Record 149 

amyloid affection in the course of exhausting cachexias, especially- 
dependent upon phthisis and osseous suppuration. Only a small 
quantity of albumen ordinarily exists in the urine. ' It is remark- 
able that Bright signalizes all three of these circumstances in his 
Case III., whose autopsy furnishes him with the type of his 
first form of renal lesion. 

Although in some cases the amyloid degeneration may be 
mistaken for anaemia, or even a healthy condition of the kidneys, 
it is generally distinguishable, even in the incipient stages, by the 
hardness and leathery consistence of the kidney, and by the hy- 
pertrophy of the cortical substance. Microscopical examination, 
as we shall presently see, easily completes the diagnosis. En 
resume, however, in the slightest (we do not say the initial) 
form of change recognizable in the kidney by the naked eye, the 
organ is smooth, polished, pale,, uniformly colored in subdued 
opaque tints that vary between grayish white and faint yellow, 
having lost its natural rosy hue, and something of its natural 
consistency, but having retained its volume and the normal 
relation of its two substances to one another. Three different 
morbid processes may be indicated by these appearances — 
anaemia, a commencement of cellular infiltration and fatty degen- 
eration, the initial stage of the amyloid affection. 

In the second form described by Bright, 

"the whole cortical substance of the kidney is converted into a granulated 
texture, with copious interstitial deposit of an opaque white substance. As 
the disease progresses, this deposit becomes more abundant, and innumerable 
specks are strewed through the kidney. Finally, granulations become visible 
externally in numerous slight uneven projections on the surface of the kidney, 
which is more or less enlarged. The whole cortical structure is often converted 
into a yellow substance like fat." 

This corresponds to the fourth form of Rayer, who repeats 
Bright's description. He observes further, that the granulations 
vary in color from flaky white to yellow, are the size of a small 
pin's head, or drawn out into lines resembling flakes of curd, 
which seem to continue with the streaks in the cones. They are 
all veiled by an extremely delicate lamina which covers them like 
a varnish. The surface of the kidney over which they are 
strewed is perfectly smooth : the cortical substance, in which they 
also appear, is hypertrophied and projects between the cones, 

' Jaccond, Clinique Medicate, 1867. 



150 Mary Putnam Jacobi 

whose volume is normal. The hypertrophy of the kidney is 
therefore exclusively at the expense of its cortex. 

Martin Solon describes these granulations (which he considers 
as a comparatively rare form of lesion) as " white, creamy, pultace- 
ous, seeming to depend rather upon a sort of interstitial exhal- 
ation than a degeneration of tissue." He places them in his 
fourth form of albuminuria. 

Frerichs' includes the granulations in his second or exudative 
stage of Bright's disease. According to him, the surface of the 
kidney is still polished between the granulations, and the capsule, 
though thickened, is easily removed. But Comil, who seems to 
associate a certai-n degree of Bright's third form (hard solutions) 
with the granulations, declares that the surface is rough and 
unequal, and that in stripping the capsule it is difficult to avoid 
removing slices of cortical substance. 

Johnson^ establishes the granulations in a third form of lesion, 
which itself is only a slight modification of the second — the 
large, pale, anaemic, wax-like (or fatty) kidney without granu- 
lations. In addition to the granulations, numerous red spots dot 
the external and anterior surface. 

Christian^ admits the granulations as the second of two princi- 
pal forms, inflammation and morbid degeneration. Jaccond 
follows Frerichs implicitly. 

Andral, in 1823," seems to have anticipated Bright, in a 
description of this form of the affection. At the autopsy of a 
young girl, who had succumbed to dropsy, the kidneys alone 
were found to be morbidly altered. "The cortical substance 
and a part of the tubular, were constituted by whitish granular 
tissue, divided in little masses which were separated by naturally 
colored reddish parenchyma." 

We may justly approximate ta the completely granular kid- 
neys the second form described by Rayer, in which the kidneys 
are enlarged, softened, the cortical substance entirely yellow, and 
the surface offering a remarkable mixture of hyperasmia and an- 
aemia. The second and the advanced degree of the third form, 
established by Martin Solon, exactly correspond to these sub- 
divisions signalized by Rayer and Johnson. 

' Die Brightische Nierenkrankheiten und deren Behandlung, 1851. 

* Loc. cit. Also Med. Times & Gaaette, 1858. 

3 Monthly Journal. 1 851. •• Clinique Medicate. 



Letters to the Medical Record 151 

The close connection that exists between the large, smooth, 
yellow non-granular form, and the large yellow granulated variety 
of renal alteration, is rendered evident by microscopical 
examination. 

Valentin,^ in his first investigations, announced that the 
granulations were formed by masses of convoluted tubes dis- 
tended by yellowish gray material, and hence more distinctly 
visible than usual. The straight canals were empty, or contained 
a small quantity of fluid. The Malpighian corpuscles were un- 
altered. Frerichs, after noticing the mixture of hyperaemia and 
anaemia indicated by the alternation of red and yellowish white on 
the surface of the kidney, also describes the convoluted tubes as 
distended by an exudated material, chiefly contained in the 
epithelial cells, and composed of fatty and proteic granulations. 
The cells lose their polyhedric form, become round, then irregular, 
and finally crumble away into a confused detritus, which blocks 
up the tubes and renders them opaque, 

A finer exudation is formed in the Malpighian capsule, around 
the vascular tuft, as soon as the obstruction of the convoluted 
tubes begins to seriously interfere with the current of urine. This 
material, consisting of fibrine mixed with fat globules, covers the 
capillary glomerulus with thick layers, interposed between it and 
the capsule, and their pressure, counterbalancing that of the blood 
in the interior of the vessels, gradually arrests the transudation of 
water. The blood often flows back, therefore, from the corpuscle 
where its presence has become useless, and the capillaries are left 
empty. 

Associated with the granular and fatty exudation is another 
of pure fibrine, which forms hyaline cylinders,^ that assume the 
form, shape, and size of the convoluted tubes. When formed in 
tubes whose epithelial cells are falling from their walls, they are 
"granulated," because the desquamated epithelium becomes 
embedded in their substance. But the cylinders, exuded into 

' Loc. cit. 

* According to Frerichs, these hyaline cylinders are formed by a simple 
process of inflammatory exudation, and identical with that which determines 
the passage of albumen in the urine. But Cornil considers them due to a 
colloid secretion from the cells, or a colloid transformation of the cells, com- 
parable to that which takes place in the colloid degeneration of the cells of the 
thyroid body. 



152 Mary Putnam Jacobi 

tubes entirely stripped of epithelium, are large, pale, and waxy, 
and perfectly smooth. 

Transverse section of the distended tubes often offers the 
appearance of little cysts, disseminated over the kidney. These 
cysts had been noticed by other observers, ^ but their nature had 
generally been misunderstood. Cornil affirms with Valentin 
that the granulations of Bright are formed by distended con- 
voluted tubes. ^ When the exudation consists of epithelial cells, 
simply desquamated, or filled with proteic (fibrinous) granu- 
lations, the granulations of Bright are grayish, opaque, or even 
demi-transparent. When the granulations of Bright contain fat, 
they become decidedly yellow in color. The uriniferous tubes 
and glomeruli in the neighborhood are normal or atrophied, and 
their collapse contributes to render the distended convolutions 
more prominent. Ecchymoses may occur near the circumference 
and they result from rupture of the capillary vessels submitted 
to excessive pressure by the obstruction to the circulation caused 
by the exuded deposit. The red points, once supposed to be dis- 
tended malpighian corpuscles, result from such a rupture into 
the extremity of a uriniferous tube. The glomeruli, as we have 
seen, are empty, or distended by fibrinous exudation — not blood. 

The pressure of the granulations known as "Granulations of 
Bright" (and which must be carefully distinguished from others, 
more commonly met with, and which will be described further on) 
constitute, therefore, but a minor detail in the morbid alteration 
in question. The essential circumstance is the degeneration of 
the epithelium in the convoluted tubes. If this degeneration is 
generally diffused, so that the cortex is uniformly distended, 
the surface of the kidney, both external and on section, remains 
smooth and uniform. If the alteration is unequally distributed, 
certain bundles of tubes will be distended, at the same time that 
others are normal or collapsed, and will consequently become 
prominent above the level of their neighbors. 

The hypertrophy of the kidney, exclusively at the expense of 
its cortical substance, its coloration, anaemia and hyperaemia, and 
its diminution of density, are all explained by this engorgement of 

» Wilkes, Guy's Hospital Reports, 1852. 

'Wilkes (loc. cit.) considers the granulations to be sometimes formed 
by the flaky deposit, scattered over the surface — the yellowish specks described 
by Bright and Martin Solon. 



Letters to the Medical Record 153 

the cortical tubes with epithelial cells, whose abnormal prolifer- 
ation has been followed by troubled tumefaction, and finally by 
desquamation. But it will be noticed that under the general 
description of the minute anatomy of the "large, white kidney" 
have been united three very different conditions. In the first, 
epithelial cells are filled by proteic granulations. Second, the 
same are distended with fat globules. Third, the uriniferous 
tubes are stripped bare, and collapse when their contents have 
been swept away by the stream of urine which continues to pass 
through them more or less freely. 

The relations of these different conditions to one another will 
be examined later. At present it is only necessary to signalize 
their existence, and to decompose the second as we have prev- 
iously decomposed the first form of alteration described by 
Bright, into three distinct lesions. 

Besides the fatty degeneration that accompanies and partially 
determines the "granulations of Bright," Cornil admits into the 
group of ''nephrites albumineuses," the stearosis occasioned 
by poisoning with phosphorus. Lebert^ and Rannier^ relate 
several cases of this lesion, whose dependence upon phosphorus 
was first insisted upon by Von Hauff in 1860,^ though in 1859 
Rokitansky had already related three cases of stearosis of the liver 
and kidneys, that he attributed to phosphoric poisoning. 

In the cellular tissue which surrounds the kidneys (remarks 
Lebert) often exist little ecchymoses, also noticeable on the 
mucous membrane of the basin and calices. Capsule is smooth, 
easy to separate. On the surface of the kidney appears the mix- 
ture of hypersemia and anaemia, already described by Rayer in 
the "large yellow kidneys," and dependent upon the obliteration 
of a part of the blood-vessels by the exudation, and the engorge- 
ment of another part in consequence of this obstruction. Volume 
of the kidney normal or increased. Fatty decoloration unequally 
distributed. Cortical substance yellow, and often notably 
atrophied. Surface smooth and shining, and of pasty consistency. 

On microscopical examination the convoluted tubes are found 
to be engorged with fat granulations, which cease suddenly on 
the threshold of the glomeruli. These latter are congested, but 
otherwise perfectly healthy. According to Cornil, the fatty 

* Archives de Medicine, Sept. 1868. » Archives de Medicine, 1863. 

J Wiirtemberger Correspondenzblatt. 



154 Mary Putnam Jacobi 

infiltration extends into the straight tubes, affecting especially the 
loop tubes of Henle, which become entirely black. 

The fibrinous cylinders appear in the urine like a black, finely 
granulated, cylindric mass, filled solid, and thickly studded 
with fat granulations. This fatty degeneration is only observed 
if death be postponed beyond the third or fourth day. It is 
accompanied by similar lesions in the liver and heart, a circum- 
stance unfavorable to the supposition that the renal stearosis is 
an essential affection of the secreting organ of the kidney. The 
rapid participation of the straight tubes, long intact in Bright's 
disease, and the scanty or doubtful amount of albumen that 
generally exists in the urine, also militate against the justness 
of Cornil's classification. But the question deserves more elabo- 
rate consideration. 

We arrive at the third and last form described by Bright. 
"The kidney is rough and scabrous, lobulated, and rising in 
numerous small eminences. The feel is hard, like that of carti- 
lage. The tubular portions are drawn near the surface: there 
seems to be contraction of every part of the organ, with less 
interstitial deposit than in the preceding variety." 

It is this form which is often erroneously called "the granu- 
lated kidney." The true granulations of Bright are, as we have 
seen, extremely small, mere specks — soft, yellow, and seeming to 
be exterior to the parenchyma. The false granulations (which 
in reality better deserve the name) are larger, the size of a hemp 
seed, hard, evidently formed by the inequalities of the paren- 
chyma itself, closely adherent to the capsule. The kidney is 
small, "contracted in every part," and has become famous as 
"the small, hard, contracted kidney," recognized and described 
by all authors. By the picturesque expression that "the tubular 
portions seem drawn near the surface" (appearance admirably 
represented in his plates) Bright indicates the extreme atrophy of 
the cortical substance, which he does not appear to recognize as 
the most special feature of the lesion. 

Rayer repeats Bright's description in his sixth form. Martin 
Solon mentions it as "induration with atrophy," in a class conse- 
crated to "accidental degenerations." Wilkes describes the 
"puckered uneven" surface of the kidney in this form, and the 
complete wasting of the cortical substance, by which the kidney 
shrinks to 3^ or ^ its normal size. As a rule, there is no pul- 



Letters to the Medical Record 155 

taceous deposit, but a large addition of fibrous tissue. Cornil 
remarks the multiplicity of lesions which may be found in this 
atrophic form — transparent granulations, calcareous incrust- 
ations of the glomeruli, atheromatous alterations of the vessels, 
cysts formed by distension of the tubes, and great abundance of 
fibrous tissue, as in the interstitial nephritis that occurs independ- 
ent of Bright's disease. P. C. M. 



Paris, July 1869. 

To the Editor of the Medical Record. 

Sir — The microscopic descriptions given by Frerichs and 
Wilkes explain the appearances in the atrophic form. The urini- 
ferous tubes, stripped of their epithelium, universally collapse, 
as they had already begun to do in the granulations. (See last 
letter.) The straight tubes also become indistinct, and at last 
almost undistingiiishable, until separated by fine needles. 
They are stifled in connective tissue, which originates both in 
the proliferation of that normally existing between the tubes, 
and the organization of the fibrinous material exuded from the 
vascular plexus which surrounds them. The malpighian cor- 
puscles in many places are wasted to half their usual size, having 
been destroyed in the crumbling away of the proteic and fatty 
granulations in the interior of their capsule. Others distend 
into little cysts, by the accumulation of urine, when the convol- 
uted tube is so blocked up as to oppose its passage, at a moment 
wlien the malpighian tuft, still unaltered, continues its watery 
secretion. Others, again, remain distended by solid exudation, 
and rise in eminences above t9ie uriniferous tubes strangled in con- 
nective tissue, thus forming the hard granulations charactertistic 
of the atrophic form. They differ from the granulations of 
Bright simply in the greater condensation of their contents. 
This is the stage of atrophy described by Frerichs as the culmin- 
ation of the disease. 

Under the first anatomical form described by Bright, we have 
considered ourselves justified in recognizing, among other lesions, 
an incipient degree of an alteration that has been described as the 
"Amyloid Degeneration." In the complete development of this 
form of renal affection the kidney is voluminous, heavy, and pale, 
and at first sight might be mistaken for the ordinary "large white 



156 Mary Putnam Jacobi 

kidney," with which, no doubt, it has often- been confounded.' 
Closer inspection, however, shows that its consistency is remark- 
ably firm, hard, and tough, even leathery. The surface is uni- 
form and smooth, without any mottling or deposit, except in the 
case of concomitant fatty degeneration of some tubuli; the 
cortical substance is hypertrophied, and the whole mass of the 
kidney appears composed of one uniform albuminous semi- 
translucent substance, except at the apices of the cones. This 
appearance is, however, only characteristic of extreme cases. In 
others,^ the cortical substance is pale yellowish white, the con- 
voluted tubes opaque, with little dots and streaks, and the straight 
tubes alone semi-translucent. In some cases (Harris) the mal- 
pighian corpuscles are scarcely apparent. In others (Jaccoud^) 
they appear upon the surface of section, white and transparent, 
like brilliant drops of dew (Meckel). 

In the autopsy performed by Harris, microscopical examin- 
ation of the fluid expressed from the kidneys, discovered blood 
cells, epithelium from straight tubes, cells filled with minute 
oil globules, and granular and fatty detritus of cells and nuclei. 
Those portions of the cortex which had appeared opaque to the 
naked eye, now showed as a black deposit contained within 
the tubes, and were seen to consist of granular matter studded 
with oil globules. The malpighian corpuscles were remarkably 
distinct and semi-transparent. 

The pathognomonic appearance of the amyloid kidney is only 
observed after the addition of iodine and sulphuric acid. A drop 
of a solution of iodated iodide of potassiimi, added carefully 
to the slice under the microscope, colors the malpighian corpus- 
cles a transparent carmine by transmitted light, orange by re- 
flected; streaks of the same color diverge from the corpuscle, 
following the direction of the afferent arteries of the tuft. The 
same reagent colors orange red the black opaque deposit that 
surrounds and invades the convoluted and straight tubes. On 
the addition of a drop of sulphuric acid, the color changes to dark 
purple, blue, and finally, after a quarter of an hour, deep red, 
brown and black. 

The seat of this deposit is principally in the coats of the 

' Wilkes' Lardaceous Diseases, Guy's Hospital Reports, 1856. 
' Harris, Lancet, 1859. 
3 Clinique Medicale. 



Letters to the Medical Record 157 

arterioles and arteries, beginning with the former.' According 
to Virchow the muscular coat is attacked Ifirst. Each cell fibre 
is replaced by a compact homogeneous substance, in the middle 
of which may be at first observed a central space corresponding 
to the nucleus which has disappeared. Gradually, however, all 
cell structure is lost, and there remains only a fusiform mass, 
in the midst of which it is impossible to recognize either mem- 
brane, or nucleus, or contents. When the muscular coat is com- 
pletely invaded, the inner and outer tunics became involved, and 
ultimately the deposit extends to the entire parenchyma nour- 
ished by the arteries. This parenchyma becomes ischaemic from 
a double cause. The small arterioles lose their propulsive con- 
tracting power by the destruction, the sort of petrifaction of their 
muscular coat ; and afterwards the thickening of the three tunics 
diminishes, and even effaces the cavity of their canal. 

According to Grainger Stewart the hyaline cylinders assume 
the characteristic coloration with iodine. But Cornil observes 
that they undergo no further change upon the addition of sul- 
phuric acid, and considers their coloration to result from simple 
imbibition of the iodine. This latter author has always found 
the deposit extended to the epithelial cells, in cases where albumi- 
nuria existed. 

There is still another and highly important form of renal 
lesion, which Bright describes, but without assigning it a place 
in his classification. In his case 14, where the anasarca was acute 
and the urine smoky and sanguinolent as well as albuminous, the 
autopsy discovered the kidneys in a different condition from 
any of the others previously examined. They were large, less 
firm, without adherence to the capsule, and of the darkest choco- 
late color, tinged with a few white points and a great number of 
black, so as to look like fine-grained porphyry. This color per- 
vaded the entire organ, but the striations of cortical and medul- 
lary substance were preserved. A considerable quantity of 
blood oozed from the kidneys upon pressure. 

This description applies to an intense hypersemia of the kid- 
ney, and is repeated by Rayer, Martin Solon, and Frerichs, in 
their first form or degree of Bright's disease. According to the 
latter, the volume of the kidney may be nearly doubled, and that 
principally at the expense of the cortical substance, which is dark 

' Virchow, Pathologic Cellulaire. Trad, frangaise. 



158 Mary Putnam Jacobi 

red and friable. The renous plexuses on the surface of the cortex, 
and surrounding the vessels of the pyramids, are distended with 
blood, and the mucous membrane of the basin covered with 
vascular ramifications. The malpighian corpuscles are red, 
distended, and more distinct than usual, and capillary apoplexies 
are frequent, either in their interior or in their neighborhood. 

The epithelium is not much altered in this form, but the canals 
are filled with coagulated fibrine, in the form of white, transparent 
cylinders. These sometimes are observed projecting from the 
uriniferous tubes, sure proof that they are formed in their 
interior. 

In the midst of this general congestion, appear grayish bands 
in the cortical substance, formed by the pyramids of Ferrein, and 
opaque white lines in the pyramids of Malpighi, consisting of the 
tubes of Henle. 

The foregoing descriptions embrace all the alterations of the 
kidney which have been observed in connection with dropsy or 
albuminous urine, in the triad constituting Bright's disease. It 
will be seen that they all involve some alteration of the malpigh- 
ian corpuscles, or the interior of the uriniferous tubes, and justify 
therefore the general name of "parenchymatous lesions," which 
has been applied to them. The "interstitial nephritis," which 
affects the connective tissue between the tubes, with its various 
forms, simple nephritis, metastatic nephritis, and chronic nephri- 
tis or cirrhosis, and the special varieties signalized by Rayer, 
toxicologic and arthritic^ nephritis, these should be most appro- 
priately noticed during the discussion of the causal relations that 
unite albuminuria to the parenchymatous affection. For, by 
the absence of this phenomenon in the case of purely interstitial 
affections, we are at once provided with a logical dilemma that 
clears half the field open to hypothesis, and forcibly limits 
investigation to the other half. 

I have enumerated the lesions of Bright's disease in simple 
succession, precisely as they might present themselves to any one 
in a series of autopsies. The relations between these lesions, 
their arrangement in separate forms or progressive stages, the 
efficient and remote causes of hyperaemia, granulations, fatty 
degeneration, atrophy, amyloid infiltration; the nature of these 

'See also Todd, Clinical Diseases of the Urinary Organs, 1757 and Ball, 
Visceral Rheumatism, Th^se de Concours, 1865. 



Letters to the Medical Record 159 

various morbid processes, their possible influence upon the char- 
acter of the urine and on the production of anasarca — all these 
questions, discussed at first, exclusively with the anatomical 
elements collected in the present letter, will form the subject of 
the next. P. C. M. 



To the Editor of the Medical Record. 

Sir — In a preceding letter we have described the renal lesions 
of Bright's disease, per enumerationem simplicem. It is now 
necessary to inquire into their logical relations to one another. 
The various conditions known as congestion — exudative nephri- 
tis, acute inflammatory nephritis, catarrhal nephritis, tubular ne- 
phritis, desquamative nephritis — fatty degeneration, smooth large 
mottled kidney, fatty stage of inflammation, interstitial nephritis, 
gouty kidney, atrophy, small contracted kidney, granular kidney, 
cirrhosis — finally, amyloid degeneration, may be regarded in the 
light of one of two hypotheses, each equally famous. They may 
be supposed to belong to diseases, as distinct and independent as 
pneumonia and phthisis, linked together by the common 
symptom of albuminuria, as these by the common symptom of 
cough. Or, on the contrary, they may be regarded as successive 
steps in the evolution of an identical process, as are the gray 
miliary granulation, the cheesy pneumonia — the softening and 
excavations in the evolution of pulmonary tuberculosis. The 
practical importance of decision between these hypotheses is no 
less evident than the speculative interest. The boundaries 
between the two great divisions into acute and chronic disease 
most urgently require settlement. If the renal lesions character- 
istic of long standing albuminuria invariably commence in 
organic degeneration, the disease is at once chronic and incurable 
from the outset. On the other hand, the acute dropsy after 
scarlatina and exposure to cold, is radically different from 
Bright's disease, and can have no more tendency to pass into it 
than endocarditis into fatty degeneration of the heart. But if 
the initial stage of certain chronic affections be identical with that 
of acute affections tending spontaneously to recovery, the hope 
may be entertained of arresting them also in their march, if 
taken in time. Finally, the obstinacy of certain other forms of 
disease may be explained and predicted by considerations drawn 



i6o Mary Putnam Jacob! 

from the differences they present in the initial lesion, differences 
which indicate their radical independence. 

Again, the value of any one symptom among the vast array 
coincident with albuminuria cannot be determined until we know 
whether it is necessarily connected with the whole range of 
Bright's disease, or belongs to a group standing apart by itself. 
Does abundance of albumen in the urine threaten uraemia as well 
as dropsy? Is diarrhoea likely to supervene when the heart is 
affected? Does haematuria indicate an exacerbation of the dis- 
ease, and the disappearance of albuminuria its cure? Will a 
patient live longer whose complexion is white or sallow? Does 
lead or alcohol tend more fatally to the production of Bright's 
disease ? If dropsy and albuminuria be the pathological signs of 
renal disease, how explain their absence notwithstanding the 
existence of extensive structural alterations of the kidney ? 

These questions, suggested at random, indicate the infinite 
confusion that results, in the absence of the elementary analysis 
that shall rigorously attach each physical sign to a definite lesion 
of the kidney, and, grouping symptoms rationally or empirically 
around such elementary lesions, anticipate their association in the 
same manner as these are known to be associated. 

We have shown that all alterations of structure in the kidney 
may be referred to one of three heads, according as they affect the 
blood-vessels, the uriniferous glands and tubes, or the inter- 
tubular connective tissue. In the list mentioned at the beginning 
of this letter, the first and last class of alterations (congestion and 
amyloid degeneration) affect the vascular structure; the second 
and third class (exudative nephritis, &c., fatty degeneration, &c.) 
involve the glandular elements; finally, the fourth class (inter- 
stitial nephritis, &c.) attack the connective tissue. Two ques- 
tions are, therefore, involved in the decision of the theory of 
successive stages. First, Can an alteration affecting one element 
of the kidney pass into another confined to the same element? 
Second, Can such an alteration pass to another element, or to 
another alteration affecting another element? and having ascer- 
tained the possibility of such progression, we must further inquire 
into its necessity or invariability. Reply to these inquiries 
demands, first, study of the combinations that may be observed 
after death, in the same kidney, of the lesions characteristic of 
each form of Bright's disease. Second, study of the combination 



Letters to the Medical Record i6i 

and order of succession that may be presented during life by the 
groups of symptoms characteristic of the same forms. 

We have already described at length the anatomical lesions. 
Before studying the combination of signs and symptoms, it is 
necessary to define the groups, and ascertain if they can be 
rationally or empirically attached to special lesions. 

And here it is necessary to distinguish. Zimmerman,' in 
despair at the variety of symptoms that may coincide with the 
same anatomical alterations, seeks in the blood and general 
state of the system an explanation that pathological anatomy 
alone is unable to give. This confusion mainly arises from the 
qualitative differences that may be introduced by qualitative 
variations. Thus, to anticipate in our description, with equal 
degrees of alteration of the glandular and interstitial elements of 
the kidney, urasmia would be imminent in the first case, and 
scarcely possible in the second. But should the interstitial tissue 
become still more compromised, ursemia might supervene with 
the same facility as in the course of tubular disease, and the 
same result be reached later and by a somewhat different 
mechanism. Time must, therefore, always be taken into account, 
in determining the relation between a symptom and any given 
lesion. 

The composition of the urine affords the best point of depart- 
ure, especially in regard to its water, urea, and the morphological 
elements that may be abnormally present. The conditions which 
determine the transudation of albumen, being themselves open to 
much discussion, the variations of this constituent are of less 
value in the elementary diagnosis of renal lesion, and will be con- 
sidered later. But in the absence of general causes, such as exist 
in cholera or fevers, the diminution of the quantity of water 
excreted by the kidney necessarily implies either alteration of the 
capillaries through which it should have been transuded, or 
obstruction of the tube through which it should have been 
excreted. Again, the presence of blood in the urine is positive 
proof that the capillaries have been ruptured by over-distension; 
of epithelium, that the urinary tubes are losing their lining ; of oil 
globules, that fat exists in abnormal quantity in the gland cells; 
of casts, that some foreign substance has exuded into the tubes 
and moulded itself upon them. If the diameter of these casts be 

^ Deutsche Klinik, 1855. 



1 62 Mary Putnam Jacobi 

less than that of the tubes lined with epithelium (rcW) it is cer- 
tain that the epithelium is still in place; if large (-p-J-Tr) that the 
tube is denuded. Casts covered with epithelium indicate des- 
quamation of the urinary tubes; granular casts, the crumbling 
away of their epithelium, after a longer duration of disease; casts 
black and shining with oil globules, extensive fatty infiltration 
and degeneration, with complete destruction of epitheliimi. 
The qualitative analysis of these elements must be controlled 
by estimate of their relative abundance. In small quantity 
they have little significance, since the fall and renewal of epithe- 
lium cells, the deposit of fat between their wall and nucleus, the 
exudation of pale, transparent, finely granular cylinders formed 
of mucine (Cornil) are ordinary phenomena of health. More- 
over, Johnson and Dickinson^ have noticed an abundant deposit 
of oil in the renal epithelium, in cases of chronic extra-renal dis- 
ease, — deposit formed here, as in the epithelium all over the 
body, to remain temporarily and then be absorbed. On the 
other hand, an immense amount of oil, associated with com- 
plete destruction of the epithelium, is as unsafe an indication of 
Bright's disease as a small quantity contained in normal cells, for 
it is characteristic of the acute, fatty degeneration caused by 
poisoning with phosphorus, ^ and is entirely independent of idio- 
pathic nephritis. Finally, a considerable amount of urinary 
deposit may be formed in consequence of lesions occupying a 
comparatively insignificant extent of the renal structure. The 
inferences drawn from it, therefore, should always be controlled 
by considerations of the quantity of urine and of urea, state of the 
blood, general symptoms, &c. 

Congestion. — The characteristic sign of congestion is the 
presence of blood in the urine, — and reciprocally, we have seen 
that the presence of blood always indicates some degree of con- 
gestion. It may exist in microscopic quantity, only recognizable 
by the form of the blood-corpuscles or be sufficient to render the 
urine smoky or black. Sanguinolent urine is necessarily albumin- 
ous, even in the absence of conditions that might determine the 
transudation of albumen through unruptured capillaries. In this 
case the albumen is derived from the effused blood, and varies in 

' Pathology of Albuminuria. 

' Cornil, These de Concours, 1868. Ranvier, Archives gen., 1863. Leh- 
bert, Archives gen., 1865. 



Letters to the Medical Record 163 

the same proportion, which is not the case when congestion 
complicates pre-established albuminuria. There are two condi- 
tions in which the kidney becomes entirely congested, ist, during 
the convalescence from certain acute diseases, — principally 
scarlatina; 2d, idiopathically, after exposure to cold. 

In the first case, the urine becomes suddenly albuminous and 
smoky, and the cellular tissue throughout the body invaded by 
cedema, but there is no pain in the loins, fever, or any exacer- 
bation of the original disease. In the second case, when the 
affection occurs in the midst of health, the general symptoms are 
more distinctly marked; there is general malaise, lassitude, per- 
haps slight fever, loss of appetite, nausea. An attack of acute 
congestion, however, remains scarcely ever limited to the re- 
pletion of the blood-vessels. The lining of the uriniferous tubes 
is irritated, and the congestion passes insensibly into the second 
form — catarrhal nephritis. 

Its characteristic sign is the presence of epithelial cells in the 
albuminous urine, mingled with the blood-corpuscles. These are 
remarkably abundant in scarlatinous albuminuria, and when 
death occurs in the course of this affection, the cortical substance 
is found nearly white, all the convoluted tubes being stuffed with 
young epithelium. According to Rindsfleisch, these young cells 
come from cells formed in the conjunctive tissue of the peripheric 
stroma, passing into the uriniferous tubes across pores pierced 
in their basement membrane. In the urine, as in the tubes, they 
are found voluminous, and in a state of troubled tumefac- 
tion distended with albuminous granulations that partially 
mask the nucleus. These disappear on the addition of acetic 
acid. Many of the cells are found in various degrees of dis- 
integration, or even filled with fat globules, which appear as soon 
as the desquamation has lasted for a few days. 

This simple catarrh, the almost immediate consequence of 
congestion (which itself may be insufficient to render the urine 
smoky, and only be manifested by the presence of blood-cor- 
puscles in the urine), is not attended with symptoms of greater 
severity than the congestion alone. In scarlatinous albumin- 
uria the renal lesion often arrests itself at this point. In the 
albuminuria supervening after exposure to cold, the affection 
generally progresses to a third stage. Exudative Nephritis. 

The transition is marked by the appearance in the urine 



1 64 Mary Putnam Jacobi 



of still another morphological element — casts or cylinders of 
various forms. 

We have seen that certain extremely pale, finely granular 
cylinders, about equal in diameter to the cavity of the uriniferous 
tubes, still invested with epithelium, may be observed in the 
urine in health, and are supposed by Robin to be formed of 
mucine. But the hyaline casts are quite transparent, and with 
firmly defined outline. They are of small diameter, and mingled 
with casts covered with epithelial cells, and others whose surface 
is moderately granular, attesting the crumbling away of the dis- 
integrated epithelium. These casts may be present at the first 
examination of the urine, the affection having begun with greater 
intensity, and advanced rapidly to the exudative stage. In this 
case the illness has been ushered in with chills and shivering, not 
very intense, but general and prolonged. The chills are followed 
by fever, pain in the lumbar region of the back, vomiting, violent 
headache. Drowsiness is a frequent and characteristic symptom, 
of great value in distinguishing between the acute nephritis and 
other febrile affections, especially small-pox at the initial stage, 
where pain in the loins is a symptom even more noticeable than 
when the kidneys are the seat of disorder. The urine diminishes 
notably in quantity, and at the beginning its specific gravity may 
even be increased, as in other phlegmasias and fevers. The re- 
duction of water is more rapid than the reduction of urea, so 
that the proportion of solids may seem relatively increased, 
although they are absolutely diminished. In a few days, how- 
ever, the impairment in the cell functions becomes manifest, and 
the specific gravity of the urine falls from diminution in the 
elimination of its solid materials. Micturition is frequent, owing 
to reflex irritation of the bladder. The urine contains blood in 
various proportions, as previously noticed, and is strongly 
albuminous — sometimes becoming nearly solid on the addition of 
nitric acid. CEdema is rapidly formed and extended, constitut- 
ing the most conspicuous phenomenon of the group, and which 
has procured for it the title of acute dropsy. Interpretation of 
the real significance of the casts found in the urine is of consider- 
able importance, since upon it has been made to depend the 
theory of the renal lesion of which they are sjinptomatic. Ac- 
cording to Frerichs, these casts consist of fibrine, exuded from 
the blood-vessels under circumstances analogous to those of any 



Letters to the Medical Record 165 

parenchymatous inflammation, and coagulated in the cavity 
of the uriniferous tubes, upon whose form they are moulded. 
Frerichs designates the lesion, therefore, as marking the exudative 
period in albuminous nephritis, and Virchow calls it Croupar 
Nephritis, the analogue of pneumonia. 

Grainger, Stewart, and Dickinson follow Frerichs in this 
interpretation, and Traube observes that the variations of 
pressure in the blood-vessels constitute a regular scale, of which 
the first degree determines the transudation of albumen, the 
second fibrine, and the third ruptures them, causing the effusion 
of the blood itself. In hsematuria, without casts, it is the capil- 
laries in the Malpighian plexus that are ruptured, while the 
larger vessels surrounding the tubes resist the pressure. Later, 
these allow the transudation of fibrine, and finally may them- 
selves give way in totality, causing haemorrhage much more 
abundant than in the first case. 

But Comil and Rindsfleisch declare that these casts do not 
present the reactions of fibrine, and are formed by a colloid 
secretion from the epithelial cells, or from the debris of the cells 
themselves, agglutinated together. In this view they are ana- 
logous, not to the exudation of parenchymatous inflammation, 
but to the mucous secretion which accompanies the epithelial 
proliferation on inflammed mucous membranes. Hence Cornil 
resumes this exudative affection, with that characterized by the 
desquamation of epithelium, under the common title. Catarrhal 
Nephritis; and Dickinson, in the same way, classes them to- 
gether as the several modes of Tubular Nephritis. 

No special justification is required for the term inflammation 
as applied to these lesions. The entire range of pathology may 
always be ransacked at any moment that it becomes necessary 
to define a lesion as inflammatory. To avoid this excursion, it 
may here suffice to adduce the pain, fever, exudation, and prolifer- 
tion of tissue (epithelial cells), as the assemblage of characters 
whose ensemble is usually defined as inflammation. The terms 
Parenchymatous Nephritis, Nephritic Albuminuria, are applied 
by the best modem writers in virtue of this well-founded 
analogy. 

By extension, however, the same term is retained, when the 

' The term croupal is used by German pathologists to characterize inflam- 
mation attended by fibrinous exudations. 



1 66 Mary Putnam JacobI 

only character of inflammation present is the proliferation of 
tissue. And this frequently occurs. 

For although epithelial casts are constantly present in acute 
febrile albuminous dropsy, the converse is by no means true. 
The disease, although clearly traceable to exposure to cold, may 
creep upon the patient silently and insidiously, manifesting itself 
by slight oedema about the ankles and puffiness of the face, with- 
out any fever, lumbar pain, difficulty of micturition, or unusual 
appearance of the urine calculated to fix the patient's suspicion 
upon the kidneys as the seat of disorder. Chemical and micro- 
scopical examination of the urine, however, discovers it to be 
decidedly albuminous, and containing blood-corpuscles, free 
epithelial cells, hyaline casts, and epithelial cylinders. Or these 
latter may succeed to simple albuminuria, without any exacer- 
bation of the general symptoms. In this case it is probable that 
the desquamative and exudative lesions are confined to a com- 
paratively small number of tubes, and are insufficient to excite 
the nervous disturbance upon which pain and fever depend. 

In other cases, these seem to be escaped in virtue of the 
unusual extent of the tubular obstruction, which, by interfering 
with the elimination of urine and urea, determines a drowsy, 
apathetic condition, in which the sensibility and capacity of 
reaction are equally diminished. 

The frequent succession of the foregoing alterations in the 
composition of the urine indicates the frequency with which one 
kind of lesion of the vascular element of the kidney may be fol- 
lowed by another kind of lesion of the glandular. The possibility 
of the sequence is fully established, and our second question 
answered before our first. To establish the necessity of this 
sequence is not so easy, because so many cases of albuminuria, in 
which the urine is loaded with epithelial cells and casts, do not 
come under observation until long after the debut, and have been 
ushered in by no acute febrile attack, or even congestion 
sufficiently violent to notably affect the color of the urine. All 
analogy shows, however, that congestion sufficient to greatly 
modify the nutrition of a part, and determine the proliferation of 
its epithelium, may be insufficient to cause the rupture of the 
blood-vessels. The supposition, so widely admitted, that the 
hyaline cylinders are formed of coagulated fibrine, exuded from 
the blood-vessels under increased pressure, necessarily implies 



Letters to the Medical Record 167 

congestion as the mechanical condition of their formation. The 
theory of cell-secretion implies it by analogy, as the vital condi- 
tion of increased activity. Finally, although the delicate 
Malpighian plexus probably ruptures under this amount of 
pressure, resisted by the tubular vessels, the exudation in the 
tubes may be sufficient to prevent the escape of so minute a 
quantity of blood, or only permit the gradual filtration of the 
blood-corpuscles. Dickinson relates a remarkable case of acute 
desquamative nephritis, supervening after scarlet fever, in which 
the tubes were so completely blocked up as to cause the nearly 
total suppression of urine, and entirely prevent the passage of 
blood, although, after death, the kidneys were found in a state of 
intense congestion. The writer justly observes, that in severe 
cases of this form of disease the absence of heematuria is a much 
more dangerous sign than its presence. 

From these considerations, therefore, and in the absence of 
any direct proof to the contrary, we may presume that the 
sequence between vascular congestion and catarrhal nephritis, or 
rather the dependence of the latter upon the former, is not only 
possible but necessary. Congestion may stop short of desquam- 
ative nephritis ; but this always originates in some degree of con- 
gestion — a fact that confirms the infiammatory nature of the 
desquamation. 

If the symptoms progress in severity, or simply present 
induration, the morphological analysis of the urine is nearly al- 
ways complicated by the appearance in it of fat globules. Their 
further description must therefore be confounded with those 
characteristics of the 

3d Class — Fatty Degeneration, etc. The pathognomonic sign 
of fat deposit in the uriniferous tubes, is the presence in the urine 
of fat globules contained in epithelial cells or studding granular 
cylinders. We have already alluded to the circumstances which 
must be taken into account in a diagnosis based upon fatty urine. 
It is only when the epithelium containing the fat is shrivelled and 
granular, when the cylinders are not too black, and the free oil 
globules not too abundant, that the fat can be referred to that 
condition of the kidney known as fatty enlargement. The 
possibility of( sequence between congestion, catarrhal nephritis, 
and fatty degeneration, as manifested by the successive appear- 
ance in the urine of blood, epithelial cells and casts, and fat 



1 68 Mary Putnam Jacobi 

globules, is as well established as that between congestion and 
desquamation. All authors relate cases in which, after an acute 
attack of albuminuria and dropsy, ushered in as described 
above, the epithelial casts are replaced by hyaline tubes studded 
with fat, the blood disappears from the urine at the same time the 
febrile symptoms subside, the albuminuria and dropsy may 
diminish, the patient considers himself well. After an interval 
of some months, during which he complains of nothing but lassi- 
tude, and perhaps frequent vomiting, the patient's illusions are 
destroyed by a renewal of the dropsy, suddenly, after fresh 
exposure to cold — or establishing itself gradually and insidiously. 
The characteristics of the urine in these cases are the same as 
in the catarrh, with the addition of fat. It is diminished notably 
in quantity and in specific gravity — the latter corresponding to 
the diminution of urea. The dropsy is extensive from the 
beginning of the disease or of the renewed attack and death 
most frequently results from effusion, in order of frequence, into 
the cellular tissue, the peritoneum, pleura, or pericardium. 
These symptoms result, as in the case of simple desquamative 
catarrh, from the blocking up of the uriniferous tubes, in this 
case by an agglomeration of granular and fatty granular masses, 
crumbling cells, and cylinders of all varieties. Whenever — by 
means of powerful diuretics — a stream of urine is sent through 
the embarrassed tubes, the dropsy diminishes. 

The same series of chronic symptoms, as we have remarked in 
the case of catarrhal nephritis, may develop themselves insid- 
iously from the beginning; after months of ill health vaguely 
defined, or in the course of some chronic disease, oedema of the 
ankles may appear, and examination of the urine detect albumen, 
epithelium, and fat. But fat is never discovered during the first 
days of albuminous dropsy occurring after exposure to cold, etc. 

On the other hand, we have seen that all cases of desqua- 
mative nephritis present an admixture of fat globules in the urine 
after a period of varying duration, and the general symptoms 
characteristic of this lesion cannot, after a certain prolongation, 
be distinguished from those of fatty enlargement. It is certain, 
therefore, that fatty degeneration may result from a destructive 
process consequent upon desquamative nephritis. 

According to a theory once professed by Johnson as exclusive, 
and still retained by this distinguished writer as applicable to at 



Letters to the Medical Record 169 

least a certain number of cases, the fatty degeneration of the 
epithelium is the initial lesion of a peculiar affection, distinct 
from inflammation, and originating in "an unsuccessful effort of 
the kidney to eliminate a superfluity of fat from the system, and 
the consequent fatty infiltration of the glandular cells." This 
infiltration — occurring as we have seen in the course of chronic 
diseases, when the fat left unappropriated by the slackened 
nutritive processes has a tendency to deposit itself temporarily in 
the epithelium all over the body — should explain the frequency of 
Bright's disease as a secondary affection. 

But, on the one hand, this fatty infiltration differs distinctly 
from the degeneration, both in its anatomical characteristics and 
the symptoms to which it may give rise. The infiltrated epithe- 
lium is normal and perfect in structure, the oil globules are large, 
abundant, and distinct, — the outline of the cell firmly defined, 
the nucleus generally visible, — and there is no sign of the 
granular tumefaction — the "cloudy swelling," characteristic 
of cellular disease. The same peculiarities may be observed in 
the fatty epithelium that finds its way into the urine, where it is 
only present in small quantity, entirely disproportioned to the 
amount of fat deposited in the uriniferous tubes and unaccomp- 
anied by fatty granular casts. The amount of desquamation 
that takes place under the influence of the fatty infiltration 
only slightly exceeds that of health, and the vitality of the 
epithelial cells is not seriously injured by the deposit. This may 
also be completely absorbed, as from other epithelium, and Beer 
has observed the renal stroma, especially the angular spaces left 
between the conjunctive cells, entirely filled with fat globules, 
presenting appearances similar to those of the fat globules in the 
intestinal villosities during digestion. 

"Within certain limits," observes Dickinson, "fat appears to 
be a temporary inmate of the epithelial cells." 

On the other hand, the disease most influential in determining 
fatty infiltration — tuberculosis — has no marked connection with 
Bright's disease; indeed, Dickinson, after numerous autopsies, 
declares to have observed even a sort of antagonism between them. 
Conversely, the affections unanimously recognized as cau- 
sal conditions of the morbus Brightii — valvular disease of the 
heart, gout, alcoholism, pregnancy, or syphilis, scrofula, sup- 
purating osteitis — ^tend to produce these amyloid degeneration, 



170 Mary Putnam Jacobi 

those interstitial nephritis, and have no influence in the form- 
ation of the large, smooth mottled kidney of fatty degeneration. 
It is probable, therefore, that Johnson's theory reposes on an 
inaccurate connection between facts, each in itself accurately 
observed, — fatty infiltration of the kidney, passage of a certain 
amount of infiltrated epithelium into the urine, — development of 
Bright's disease in the course of chronic extra-renal affections 

P. C. M. 



SOME DETAILS IN THE PATHOGENY OF PYAEMIA 
AND SEPTICEMIAS 

REMARKS BEFORE THE MEDICAL LIBRARY AND JOURNAL ASSOCI- 
ATION OF NEW YORK. 

As I understand the object of this Association, it permits its 
younger members to submit the questions that may have especi- 
ally interested them, to the judgment of others older and more 
experienced than themselves. This is why I venture to make 
some remarks on a subject, which a rather prolonged sojourn in 
the hospitals of a great metropolis has forced most prominently 
upon my own attention. 

The study of putrid and purulent infection, though it orginate 
in the province of the operative surgeon, immediately rises into 
the sphere of general pathology, and touches upon problems of 
the keenest interest to the physician. Moreover, by a singular 
fatality, the methods adopted to remedy the effects of accidents, 
expose to many of the same dangers as the accidents themselves ; 
and operations for many diseases of internal origin accumulate 
upon the unfortunate patient the additional perils of an external 
traumatism. Finally, while men are more especially exposed 
to the superfluous traumatisms of war, women are compelled 
to incur the inevitable tratmiatism of childbirth; and the ulti- 
mate danger is in many cases the same. 

To judge by certain assertions, one might suppose that this 
danger had been so much diminished by appropriate treatment, 
that it now presented no more practical interest than that of the 
plague. The admirers of Professor Lister have far surpassed his 
own confidence in the virtues of carbolic acid. In the Dublin 
Quarterly for 1869, Mr. McDonnell aflirms that treatment by 

' Reprinted from The Medical Record, 1872. VII, p. -j^. 

171 



172 Mary Putnam Jacobi 

Lister's method has attained perfection; and that when a wound 
has been dressed with carboHc acid, and its arteries secured 
by torsion, it is almost certain to heal easily, while the temper- 
ature of the body does not rise above ioo°. Lister himself, 
in his famous paper published in the British Medical Journal for 
1 867, is not so sanguine. He gives no statistics, but observes that 
since the employment of carbolic acid for the dressing of wounds, 
his wards, formerly the most unhealthy in the Glasgow infirmary, 
have become comparatively healthy, and that he no longer dreads 
as before, the advent of compound fractures. In St. George's 
Hospital Reports for 1 868, Mr. Holmes gives the result of experi- 
ments made with carbolic acid in forty cases. Lacerated wounds 
and abscesses did remarkably well under this treatment; all 
recovered. Of eight cases of compound fracture, four recovered 
and four died — two of pyasmia, one of tetanus, one, on fourth day, 
without metastatic abscesses, the case being complicated with 
renal disease. Mr. Holmes had twelve cases of incised wounds 
and operations, including two amputations of the breast, but only 
two involving section of the bones. One of these was a Chopart's 
amputation of the foot ; patient recovered after an attack of ery- 
sipelas; the other, an amputation of a metacarpal bone, followed 
by death from pyaemia. In this case the patient had diseased 
kidneys. 

In the last October number of the Archives de Medecine, Dr. 
Labbee reviews the English statistics, and points out that, even 
in Lister's wards, the results of carbolic acid treatment are much 
less brilliant than was at first supposed. Thus, previous to this 
treatment the deaths after amputations were 41 to 126, or i in 3; 
after its adoption, they were 30 in 80 cases, or i in 2.6. During 
the last six months Dr. Labbee had extensively employed carbolic 
acid, with the most scrupulous attention to the details insisted 
upon by Lister, and nevertheless nearly all his amputated 
patients had died. This lugubrious statement corresponds 
entirely with the facts that I have had an opportunity of observ- 
ing closely. For at least three years the use of carbolic or phenic 
acid has been almost universal in the great surgical wards of the 
Paris hospitals ; but the mortality has not been notably modified, 
and remains higher than that of London. 

These remarks, with no pretension to statistical value, are 
merely intended to show that the antiseptic treatment is by no 



Pathogeny of Pyaemia and Septicaemia 173 

means infallible. The phenic acid of the modems is not a pana- 
cea, any more than the famous sage of the ancients. It follows 
that the doctrine upon which its employment is based, is not 
sufficiently comprehensive to include all the cases to which it is 
applied. This doctrine is sometimes announced in a proposition 
that rather unfairiy combines the opinions of Roser on miasms, 
and of Pasteur on animal germs. It is sometimes said that these 
germs constitute hospital miasms, and act either directly, being 
themselves absorbed into the blood, or indirectly, after having 
determined the putrefaction of traumatic fluids. The absorption 
of fluids thus putrefied is sufficient to account for the most various 
surgical accidents — phlebitis, erysipelas, pyaemia, septicaemia, 
hospital gangrene. In virtue of the assumed unity of their 
aetiology and of their nature, these several affections are asserted 
to be equally amenable to a single mode of treatment. This 
consists in the destruction of animal germs, first in the atmosphere, 
by purification of the air; second, upon the wound itself, by dress- 
ings with carbolic acid. 

But, in the first place, the animal germs to which Pasteur 
attributes the mechanism of putrefaction do not exist merely in 
impure air, but even in tolerably pure air, unless it be absolutely 
free from animal or vegetable dust — such air, indeed, as may be 
brought from the summit of Mt. Blanc. To prevent putrescible 
substances from putrefying, it has been shown necessary to seal 
them hermetically, so as absolutely to exclude air. Donn^ 
experimented on an egg, which he carefully enveloped in cotton 
wool, and then obliquely pierced by a knitting-needle, previously 
heated to destroy any germs that might be clinging to it. By 
means of this puncture air was admitted to the interior of the egg, 
but only after having been filtered by the passage through cotton. 
The egg putrefied, as it will not do if it be covered with an imper- 
meable varnish. But Pasteur asserted that the precautions 
taken had not been sufficiently severe; that it was possible to 
admit some of these ubiquitous infusoria during the manipulation 
of the experiment. How much more, then, in any wound not 
treated by absolute occlusion ! 

In the second place, the researches of Bechamp and Estor, 
communicated to the Academic des Sciences in 1868, indicate 
that, though the access of air be essential to putrefaction, yet the 
presence of bacteria in animal putrefying substances does not 



174 Mary Putnam Jacob! 

depend on their introduction from without, but on the develop- 
ment of germs already contained in the elements of the tissues 
themselves. Especially in the cells of the liver, both in man and 
in other animals, these observers have discovered certain spheri- 
cal granules which they call microzymes. These remain spheri- 
cal as long as the organ is in health, and constitute a normal 
necessary part of its elements. But when the tissues are separ- 
ated from their vital connections and exposed to the air, these 
granules at first arrange themselves in strings, and finally assume 
the shape of moving or motionless rods, presenting all the appear- 
ance of the vibriones known as bacteria and bacteridia, and des- 
cribed by Davaine. ^ Fragments of liver placed in water contain- 
ing either sugar or starch, showed a development of bacteria in 
twenty-four hours. But if immersed in ordinary water, the 
development was delayed five to thirteen days. Further, what is 
extremely important to notice, the addition of creasote or of 
phenic acid in no wise affected this proliferation of animal germs, 
unless it were made in a quantity sufficient to coagulate animal 
tissues. That these bacteria came from the microzymes into 
which they were seen to grade, and not from the surrounding 
air, seems proved by the fact that they were always discovered in 
the fragments of tissue before they appeared in the water in 
which these were immersed. 

In the Quarterly Journal of Microscopical Science for last 
October, Burdon-Sanderson has shown, by most careful experi- 
ments, that the microzymes never come from the air. According 
to this writer, they frequently abound in water, so that a drop 
or two of ordinary spring water added to a test solution is suffici- 
ent to determine in it the development of microzymes and of 
bacteria. But if the water so added be boiled and the whole 
placed in a glass that has been superheated, no microzymes will 
appear, even though the liquid be left exposed to the air. In the 
latter case, however, torula-cells appear in as great abundance as 
if the liquid had not been boiled. It is thus shown that no con- 
nection exists between the microzymes destined to develop into bac- 
teria and the torula-cells that multiply into fungi. The air is 
charged with these latter, while the former abound in animal 
and vegetable solids and fluids. 

To test the influence of bacteria, apart from that of the morbid 

^ DicHonnaire des Science Medicates, Art. "Bacteries." 



Pathogeny of Pyaemia and Septicaemia 175 

fluids with which they were associated in Davaine's experiments, 
Leplat and Jaillard^ injected the veins of animals with fluids con- 
taining bacteria obtained from decomposing vegetable infusions. 
Such injections were productive of no inconvenience whatever. 
Analogous experiments were made by J. G. Richardson, as re- 
lated in the American Journal of Medical Sciences for July, 1868, 
p. 291. He swallowed from one to four fluid ounces of water, 
rendered putrid by two or three days' contact with meat, and 
swarming with vibriones. A drop of blood drawn half an hour 
after the ingestion of one fluid ounce, presented only a single 
vibrio. But with a larger dose and an hour's interval the number 
greatly increased. Twelve were seen in as many minutes, and at 
one time there were three in one field. In two hours, however, 
these had entirely disappeared, their presence in the blood having 
occasioned no other inconvenience than slight headache, furred 
tongue, and some diarrhoea. 

Thus, left to themselves in contact with healthy living tissues, 
vibriones are rapidly eliminated without causing any damage. 
Moreover, as Davaine observes, in a medium composed of sub- 
stances in full putrefaction, these animalculae are also unable to 
sustain life. They live upon organic matter that is just begin- 
ning to decompose; they cannot determine the decomposition of 
living tissues; their germs cannot develop to the potency of 
bacteria unless they have free access to oxygen; finally, when the 
organic matter in which they are imbedded is dead, and resolved 
into inorganic elements, the vibriones die too. Hence, though 
Feltz and Cohn have discovered them in the fluids of putrefying 
wounds ; though Ranvier has found them near the seat of a frac- 
tured bone affected with osteo-myelitis ; though he has further 
found germ-granules in metastatic abscesses, — yet, these marvel- 
lous little organisms cannot be rendered directly chargeable for all 
the accidents of putrid and purulent infection; nor their de- 
struction be considered an assurance of security against these 
formidable complications of wounds. For, ist, in air that has 
been sufficiently purified to avert certain forms of disease, as 
hospital gangrene and the more malignant kinds of septicaemia, 
the germinal matter of vibriones is still found in considerable 
abundance, so that animal fluids or tissues exposed to the air 
necessarily decompose. 

' Comptes Rendus de VAcademie des Sciences, 1867. 



176 Mary Putnam Jacobi 

2d. Positive experiments have shown that bacteria by them- 
selves, though introduced into the blood, are not injurious. 
Further: Bergmann has shown that the dried residue of pus re- 
tains its toxic properties, though it have been heated to 212°, 
or treated by alcohol of 96 per cent.; and either procedure is 
accounted sufficient to destroy animal germs.' 

The above-quoted experiments of Burdon-Sanderson tend to 
show that the vibriones of the air, which are a cause of putre- 
faction, differ essentially from the microzymes of animal fluids, 
whose development may be only an effect. But the develop- 
ment of these latter to bacteria may act like that of all other 
vibriones, in favoring putrefaction. Hence the accession of air 
to a wound would work in two ways : it would admit atmospheric 
germs, demonstrated agents of putrefaction ; and it would furnish 
the oxygen requisite for the development of microzymes, probable 
agents of putrefaction. The one and the other class of vibriones 
— innocuous if themselves absorbed — only act by determining 
the alteration of traumatic fluids ; and these once altered become 
toxic, though the causal germs be excluded or destroyed. 

That the accidents resulting from wounds depend upon the 
introduction into the economy of substances formed upon them is 
shown : (a) because the artificial introduction of these same sub- 
stances, by injection into the veins, is followed b}^ the same symp- 
toms as occur spontaneously when they are left long in contact 
with living membranes; (b) because direct experiment proves 
that the capacity of absorption from the surface of wounds is 
very great. 

Two great classes of infection may be formed: ist. That 
which depends upon primary absorption from the wound previous 
to the growth of granulations or the formation of pus; 2d. That 
which supervenes after suppuration, and the complete disappear- 
ance of traumatic fever. The first class constitutes septicaemia; 
the second, pyemia, or purulent infection. 

It is noteworthy that septicaemia is developed at a time 
when absorption from the wound is slowest; pyaemia, when it has 
begun to be most active. Demarquay has shown that an iodic 
solution placed on a recent wound will be absorbed in from fifteen 

' On this last point, however, there is at least room for doubt, since 
Wyman's experiments {Am. Jour. Set., 1867) have shown that certain infus- 
orial germs will retain their vitality even after four hours' boiling. 



Pathogeny of Pyaemia and Septicaemia 177 

minutes to an hour. But after application to a granulating 
wound, iodine may be detected in the urine and saliva in ten, 
eight, six, or even four, minutes. It would seem, therefore, that 
the accidents of septicaemia depend on the absorption of some 
substance more diffusible than that which is the origin of pyaemia, 
since it acts more quickly, though at a time when absorption is 
less active. 

The wounds in which pure septicaemia originates may affect 
exclusively the soft tissues. Thus, in wards where pyaemia was 
the most frequent disease, I have seen septicaemia develop as a 
consequence of an operation for a double prolapsus of the uterus 
and rectum, where an attempt was made to extend the perinaeum 
backwards by a suture that should include a part of the enor- 
mously distended anal sphincter. 

Septicaemia is frequent after operations for strangulated 
hernia or the extirpation of tumors, and often complicates the 
peritonitis occasioned by ovariotomy. But in wards where 
pyaemia and septicaemia were both endemic, I have been struck 
with the exemption of patients who had suffered amputation of 
the mammary gland. On the other hand, the extirpation of a 
fibro plastic tumor from the deltoid muscle was followed by a 
typical development of septicaemia. The traumatic fever set in 
within twenty-four hours after the operation, and, instead of 
abating, persisted, and gradually rose into all the violence of the 
septicaemic fever. 

This form of surgical fever is frequent as a consequence of 
diffused acute phlegmon of cellular tissue, even when this is 
unaccompanied by osteo-myelitis. It constitutes those pecu- 
liarly malignant forms of puerperal fever where death super- 
venes with great rapidity, and where, after death, the uterus 
presents no trace of phlebitis or of lymphangitis. These cases 
are exceptional. 

It is a very remarkable circumstance that gunshot wounds, so 
excessively dangerous when they affect the bones, are so fre- 
quently innocuous when confined to the soft tissues. I had 
abundant opportunity for observing this fact, in the case of num- 
erous shell wounds that came under my observation during the 
siege of Paris. In wards where acute diffused phlegmons fre- 
quently proved fatal by generating septicaemia, flesh-wounds 
caused by the explosion of shells healed readily, even though, 



178 Mary Putnam Jacobi 

as in one case, the victim was a woman six months pregnant, and 
miscarried after a triple injury in face, thigh, and leg. 

A curious case of impunity, even though the bone was in- 
volved, was that of another woman who had been for four years 
an inmate of the hospital on account of chronic rheumatism in 
shoulder, wrist, and knee-joints, all of which were more or less 
completely ankylosed. During the bombardment, a shell 
exploded in the hospital ward, and carried off this patient's 
right arm about three inches below the shoulder-joint. It 
was a very clean amputation, with very slight haemorrhage; and 
but little trimming of the wound was needed to make a neat 
stump, which was speedily covered by fleshy granulations. Not 
merely did the patient escape without any signs of septicaemia or 
purulent infection; she even had no traumatic fever. I attri- 
buted this remarkable exemption to the pre-existence of chronic 
adhesive inflammation, which had rendered the tissues — lym- 
phatic, cellular, osseous, and to a certain extent even the veins — 
impermeable to the septic material arising from the traumatism. 

The behavior of gunshot flesh wounds resembles that of those 
made with caustics as compared with those made by the bistoury. 
It is not my province to insist upon the practical advantages of 
the method so eulogized by Maisonneuve, but their bearing upon 
the theory of septic and purulent infection is of importance. 
The facts tend to show that tissues killed outright, by chloride 
of zinc or the actual cautery, present far less chances of infection 
than those that die slowly and, during a long period, offer to 
absorption the successive products of their decomposition. 
They appear, moreover, to block up the roads of absorption, and 
not to afford the media for diffusion constituted by loose diffluent 
tissues. 

Septic absorption occurs to a greater or less extent whenever 
decomposing animal matter is brought in contact with living 
membranes, and seems to be independent of the state of the 
veins. 

The condition of the lymphatics is of much more importance. 
For at the time that septicaemia develops, the lymphatics, torn 
by the traumatism, gape open into the wound, while later they 
are closed by fleshy granulations. Septicaemia, which precedes 
the formation of these granulations, likewise, in typical cases, 
precedes the formation of pus. This does not normally occur 



Pathogeny of Pyaemia and Septicaemia 179 

before the third day; and if symptoms of septic poisoning have 
appeared previous to its establishment, suppuration may be 
indefinitely delayed, or the pus be replaced by a thin sanious 
liquid, in which pus-corpuscles are rare. According to Robin, 
the decomposition of pus is always a consequence of the general- 
ized infection, and not its cause. 

As might be inferred from this apparent connection with the 
lymphatic system, the full development of septicaemia is often 
preceded by a lymphangitis. But it is extremely curious to 
notice that, should this lymphangitis be immediately followed 
by tumefaction or phlegmon of the nearest lymphatic glands, 
or by an attack of erysipelas, the general infection seems to be 
averted. I have in my notes three cases of compound injuries 
of the fingers, followed by abscess in the axilla, which in one case 
had been preceded by a subacute phlegmon of the arm; in an- 
other, by the red streaks of superficial lymphangitis ; in the third, 
by a probable affection of the deep lymphatics. All these cases 
resulted in recovery, in the same wards where patients affected 
with quite similar injuries were constantly succumbing with 
symptoms of septico-pyaemia. The occurrence of erysipelas 
seems also frequently to ward off the graver affection. In two 
cases of carbuncle treated by extirpation, the occurrence of a chill, 
in connection with a sudden drying and glazing of the wound, 
was regarded as an ominous forerunner of septic infection, until 
the advent of a local erysipelas unexpectedly changed the progno- 
sis. In another case, an operation for strangulated hernia in a 
woman was followed by an attack of erysipelas on the face, from 
which the patient recovered. She subsequently succumbed 
to exhaustion, but never presented either symptoms or lesions of 
putrid or purulent infection. These facts, and certain statistics 
showing the epidemic alternation of erysipelas with graver 
surgical affections, bear testimony in favor of the theory that 
ascribes erysipelas to a diffused inflammation of the lymphatics 
of the skin, caused by the passage through them of irritating sub- 
stances. It is upon this theory that Maisonneuve has based his 
treatment of erysipelas by application of a blister directly to the 
inflamed surface, for the purpose of drawing off septic material in 
a profuse discharge of serosity. 

The succession of symptoms in septicaemia generally occurs 
as follows: The traumatic fever, instead of abating, persists, or 



i8o Mary Putnam Jacob! 

abates only imperfectly. The suppuration, that should have set 
in on the third day, is delayed; and sometimes the wound becomes 
glazed and dry, or points of gangrene appear in tissues that 
seemed at first sufficiently vitalized. Sometimes, as was the case 
with the patient submitted to a perinaeorrhaphy, a fugitive local 
erysipelas appears, to disappear after a few hours. About the 
fourth day occurs a single chill, often quite violent, immediately 
followed by a notable rise of temperature. By the fifth day 
the sutures in the wound give away, and the tissues begin to melt 
down into an increasingly putrescent detritus. At the same time 
the pain of the wound is diminished, and this local blunting of the 
sensibility rapidly extends to the entire nervous system. The 
patient becomes absorbed, indifferent, finally agitated and 
delirious. The delirium is sometimes muttering, often violent. 
The fever is remarkable for its continuance; morning remissions 
are slight. Under this continued fever the body emaciates; the 
cheeks become excavated, and covered with a dry parched flush ; 
the eyes are injected; the tongue and lips retracted and blackened 
with fuliginosities ; the whole aspect of the patient recalls that of 
typhoid fever, and the occurrence of diarrhoea completes the 
resemblance. 

The peculiar circumstance about the pathological anatomy 
of pure septicaemia is its negative character. There is no trace of 
phlebitis, thrombi, or metastatic abscesses. The veins are all 
permeable, but filled with diffluent black blood like molasses. 
The viscera are nearly all softened and congested, as in typhus. 

In artificial septicaemia, induced by the injection of putrid 
matters into the veins, there is often diffused pneumonia, or there 
may be patches of gangrene in the lungs. The most notable 
lesion, however, exists in the intestinal mucous membrane, which 
is tumefied, hyperaemic, and softened. This lesion corresponds to 
the sanguinolent diarrhoea, which is an invariable symptom during 
life, and both lesion and symptom point to an effort at elimination 
of the poison by the intestinal tube. That the lesion is so ex- 
tremely marked in animals, while it is slight or wanting in human 
victims, indicates that the effort at elimination is greater in the 
former case than the latter, and helps to explain, therefore, the 
greater resistance of dogs to the disease. 

Finally, a very notable peculiarity of septicaemia is its variable 
degree of intensity — variable as the conditions which may give 



Pathogeny of Pyaemia and Septicaemia i8i 

rise to it. There is the terrible septicaemia of malignant forms of 
puerperal fever, that destroys life in a few days; there are the 
much milder forms, that almost invariably occur when decompos- 
ing animal fluids are brought in contact with any surface of the 
body in such a way that any part of them may be absorbed. 
The retention of a piece of the placenta in the uterus will give rise 
to all the symptoms of an incipient septic fever, as I had an oppor- 
tunity to observe in a case the other day. Nay, even in perfectly 
normal conditions, recent accurate observations have noted a 
rise of temperature as a general occurrence about twelve hours 
after parturition. This phenomenon is precisely analogous to 
the well-known traumatic fever, and the elementary conditions 
are the same, namely, the contact of decomposing non-purulent 
fluids with living membranes capable of absorption. 

In these cases, the general disease seems to be directly con- 
nected with the wounds, and this, not in virtue of the nervous 
shock they have inflicted, but of the decomposing liquids, or of 
some element in them, that they place in contact with live animal 
membranes. The essence of the general disease lies in the fever, 
or rise of temperature; and of all the causes that have been 
invoked to explain the rise of temperature in such cases, that of an 
acceleration of the molecular metamorphoses of the blood and 
tissues is infinitely the most probable. For the fever may be 
determined, either, as I have said, by contact with animal mem- 
branes of substances themselves undergoing rapid chemical meta- 
morphoses, or by an injection of these same substances into the 
blood, as in Billroth's experiments.^ In these experiments there 
was no chill, but the temperature rose immediately as high as 
40.5°C., and other symptoms of septicemia followed, as diarrhoea 
and great prostration. Recovery frequently took place. In 
some cases, where the amount of injected material had been very 
large, death occurred, and then the only visceral lesions discover- 
able were diffused congestions, especially of the intestinal mucous 
membrane. From these experiments the gravity of septicaemia 
is shown to be in direct proportion to the amount of putrid mat- 
ters thrown into the blood, although in every case they deter- 
mined a rise of temperature. Below a certain limit of quantity, 
they could be supported; but above that limit, they occasioned 
more violent symptoms, which finally proved fatal. This grad- 

^ Archiv fiir Klinische Chirurgie, 1862. 



1 82 Mary Putnam Jacobi 

ation corresponds to that furnished by clinical experience — to the 
immense variety in the severity of septicaemic symptoms, which 
are least of all after normal parturition; greater after wounds, and 
in proportion to their extent ; greatest of all when, long after the 
original shock, new tissues have sloughed by the invasion of 
hospital gangrene. There are, therefore, the strongest reasons for 
accepting the recent doctrine of Billroth, which interprets trau- 
matic fever as a form of septicaemia, and septicaemia as a simple 
extension or aggravation of traumatic fever. 

This analogy suggests that of numerous other affections in 
which septicaemia plays a prominent part, as hospital gangrene, 
carbuncle, malignant pustule, typhoid fever, variola, tilcerative 
endocarditis, even erysipelas when the effort at cutaneous elimin- 
ation has proved unsuccessful. In all these cases the evolution of 
the affection seems to be connected with the presence in the blood 
of rapidly decomposing substances, whose metamorphoses 
accelerate those of the animal tissues, including the blood, and 
thus raise the temperature of the body. 

It is in virtue of this rise of temperature that septicaemia is 
allied to pyasmia ; for the injection of pus into the veins, even when 
it produces no other effect, generates fever as intense as that 
produced by the injection of putrid non-purulent fluids — fever 
which may end in death. In other respects the symptoms and 
march of pyaemia are quite different from those of septicaemia. 

As every one knows, pyaemia originates most frequently in 
some lesion of bones, which places the wounded osseous tissue 
in immediate communication with the air. The larger the bone, 
the greater the danger, which is most to be dreaded after injuries 
of the femur. Who is not familiar with the train of events that, 
in such a fatally large number of cases, follows upon an amputa- 
tion of the thigh? The patient may have recovered from the 
initial traumatic fever, and on the fourth or fifth day be appar- 
ently in very good condition. Suppuration, which set in on the 
third day, becomes profuse, but the pus remains thick, yellow, 
laudable, or only slightly offensive in smell. Thus, suppuration 
precedes the invasion of pyaemia, while the symptoms of septicae- 
mia generally begin before the establishment of suppuration, or 
arrest it if pus be already formed. 

The wound is extremely painful, and its sensitiveness seems 
to increase instead of diminishing. The process of dressing the 



Pathogeny of Pyaemia and Septicaemia 183 

wound throws the patient into an agony; but when this is over, he 
is comparatively comfortable, often extremely hopeful and 
sanguine. One day, generally between the fifth and tenth, the 
nurse observes that the patient has eaten less than usual. In 
reply to inquiries, however, he asserts, sometimes quite vehe- 
mently, that he is perfectly well. A day or two later he acknowl- 
edges having had a slight chill or fever, that he refers to only on 
account of the persistent questionings of the surgeon. Some- 
times several days, even a week, will elapse before the chills are 
repeated; sometimes they follow in rapid succession, coming 
every day, or even twice and thrice a day. It is extremely rare 
that only one chill precedes the invasion of fever; and even then, 
this invasion only occurs after a certain interval. The chills are 
ver>' apt to return after the establishment of fever, and checker 
its course in a way never seen in pure septicaemic infection. 

The rise of temperature occurs sometimes after the complete 
subsidence of the traumatic fever, in notable contrast with that of 
typical cases of septicaemia. It is rarely as rapid, as intense, or as 
continued as in the latter case; for some time it presents very 
marked morning remission, and only gradually rises into 
continuity. 

The appetite and strength fail, and the patient is conscious of 
his increasing weakness, and complains of it, as is never the case 
in septicaemia. Hence it seems much more notable. The skin 
and sclerotics assume the characteristic yellow hue, extremely 
unlike the red parched flush of septicemia, and analogous to that 
of cancerous infection, with which Billroth compares it. It is 
one of the forms of jaundice described by Gubler, dependent on a 
destruction of red corpuscles in the blood. The tongue of the 
patient becomes dry, but never blackened by fuliginosities as in 
septicaemia. The intelligence remains clear, but the mind begins 
to be darkened by gloomy forebodings, by a semi-consciousness of 
the dissolution of vital forces already begun. 

During this time the aspect of the wound is little changed, 
the suppuration is abundant, according to Billroth is increased, 
and my own observations accord with this statement. An exten- 
sion of suppuration takes place, as the older writers would say, 
and is manifested in one or more of three different ways. 

In the first place, cold abscesses may form in different parts of 
the cellular tissue, generally of the extremities, sometimes in the 



1 84 Mary Putnam Jacobi 

more decumbent portions of the trunk. In the second place, 
purulent effusions may take place into the articulations, or serous 
cavities, and that with extraordinary rapidity. This purulent 
arthritis is a very common manifestation of infection during the 
puerperal state. I remember one case especially, which I had an 
opportunity of observing at the clinique, that might be con- 
sidered as a type of this class. The patient had had an attack of 
subacute metritis, which was subsiding, when she complained 
of pain in her left elbow-joint; and in the course of twenty-four 
hours the articulation became evidently filled with liquid, swollen, 
extremely tender, but without any inflammatory redness. The 
only other symptoms presented by the patient were diarrhoea, 
and a certain dulling of the intelligence. M. Depaul immediately 
pronounced a fatal prognosis, which was justified four or five da^'-s 
later by the death of the patient with all the symptoms of puru- 
lent infection. 

These external suppurations, however, indicate a com- 
paratively curable form of the disease, and, when manifestations 
of the infection are confined to the cellular tissue or the articu- 
lations, the patient may recover. I have seen three curious 
cases of this category. After a compound fracture of the tibia, 
a patient was affected with cold cellular abscesses in various parts 
of the body, and with purulent effusion into one of the knee- 
joints; yet he ultimately recovered. 

In another case, also of compound fracture of the tibia, 
the patient had had three chills, and an abscess had de- 
veloped in the thigh. After the administration of quinine, the 
course of the infection seemed to be arrested, and the patient 
recovered. 

In a third case, the purulent infection had originated in an 
anthrax, which had been followed by abscesses in the breast, 
glutasal region, and leg, and by an effusion probably purulent, in 
the knee-joint. Notwithstanding this multiple suppuration, the 
patient recovered, and the articular effusion was reabsorbed 
with the rapidity so remarkable in such cases. 

These cases recall the experiments of Sedillot upon dogs, 
where injection of pus into the veins was followed by the develop- 
ment of external abscesses, but finally by recovery. 

External suppuration or suppurative inflammation of serous 
cavities may, however, of itself prove fatal, as in a case that I saw 



Pathogeny of Pyaemia and Septicaemia 185 

at the Children's Hospital, where purulent infection is com- 
paratively rare. A child four years old had been submitted 
to Chopart's amputation of the foot, on account of a fungous 
arthritis, accompanied by necrosis of some of the medio-tarsal 
bones. The first few days after the operation passed very well; 
then secondary fever set in, and was followed by symptoms of 
arthritis in both elbow-joints, and of double pleural effusion. 
Death occurred about a fortnight after the operation, and at 
the autopsy were found abundant purulent effusions in the arti- 
culations, in both pleural cavities and in the peritoneum. This 
purulent peritonitis had been latent and quite painless, and had 
probably taken place during the last days of existence, when 
sensibility was blunted. There were no traces of metastatic 
abscesses in lungs, liver, or spleen. 

These metastatic visceral abscesses constitute the third form 
of generalized suppuration, and the lesion most characteristic of 
pyaemia. The invasion and march of the disease seems to coin- 
cide exactly with their development and evolution. To them is 
due the dyspnoea that occurs early in the disease, while that of 
septicEemia, dependent on the poisoning of the mass of the blood, 
does not supervene till later. The respirations are rarely below 
forty, sometimes as high as fifty or sixty. With the progress of 
one or the other of these suppurations, the prostration of strength 
increases. All the powers of life seem to be gradually dissolved 
apart from one another, and drift away separately before sinking 
down into the sea of nothingness that is rising to engulf them. 
Hence towards the close, a peculiar incoherence of the mental 
faculties and of speech, that is quite distinct from the delirium of 
septicaemia. The patient will interpolate absurdities in the midst 
of a conversation whose general tenor is reasonable; he has tem- 
porary hallucinations of vision; he loses all capacity for com- 
parison, and consequently for astonishment; his mind resembles 
that of a person in the incipient stages of dementia. 

This ataxia of the intelligence finally extends to the spinal and 
peripheric nervous system; there is carphologia, the wandering 
involuntary movements by which the patient seems vainly 
endeavoring to clutch at the life that is slipping away from him. 
Finally, consciousness is entirely gone — the patient lies on his 
back with his eyes closed, already half a corpse. I have seen one 
case where this condition was prolonged a month, and Mr. Paget 



1 86 Mary Putnam Jacobi 

relates similar cases of chronic pyaemia, where, as in Edgar Poe's 
story, the patient seems to have been magnetized when at the 
point of death, and his dissolution arrested, but left constantly 
imminent. It is during this last period that the suppuration on 
the wound diminishes. 

The autopsy of patients who have succumbed to pyaemia 
reveals one or other of three characteristic lesions, and very 
frequently a combination of all of them : osteo-myelitis ; venous 
thrombi, with or without phlebitis; visceral abscesses, or purulent 
effusions into the articulations or serous cavities. 

The osteo-myelitis, whose presence might have been inferred 
from the constancy with which pyaemia is associated with lesions 
of the bones, is extremely frequent. M. Ranvier, in an article 
published in the Lyons Medicate for last May, observes that he 
found it in all the autopsies made at Val de Grace during the siege. 
M. Gosselin, in his clinical lectures, always insisted upon this 
coincidence, and has referred to it again in the recent discussion 
at the French Academy. I have certainly had abundant oppor- 
tunity to observe it myself. 

This osteitis is always of the rarefying variety ; the bony tissue 
is highly vascularized, and the surface of a section shows the 
trabeculse to be red and softened, and the spaces they enclose 
enlarged, and filled with grumous sanguinolent matter. The 
medtdlary canal is filled with a vascularized pulpy mass, whence 
the fat has disappeared, a most noteworthy circtmistance. A 
very characteristic detail is the projection of a portion of the 
mass from beyond the medullary canal. 

Of less importance for the pathogeny of pyaemia is the thicken- 
ing of the periosteum, and its frequent detachment from the bone 
by neoplastic material formed beneath it. 

There are two noticeable facts about a bone in this condition : 
1st. That all its cavities, both the medullary canal and the spaces 
between the trabeculae, instead of being obstructed by solid clots, 
are filled with loose, pulpy, diffluent matter, exactly calculated to 
offer a medium of diffusion for liquids carrying solid particles in 
suspension. 2d. That the fatty matters of the meduUa, so 
eminently adapted to rapid movements of chemical metamorpho- 
sis, are as ready for absorption as are the liquids on the surface 
of the original wound. 

Not only is osteo-myelitis an almost invariable attendant on 



Pathogeny of Pyaemia and Septicaemia 187 

fatal cases of compound fracture, but it may constitute the sole 
perceptible cause of pyaemia, as when the latter supervenes upon 
an acute necrosis (so called), or even, under certain circumstances, 
upon simple fracture. I have observed an example of pyaemia in 
an old man affected with simple fracture of the neck of the femur 
which had begun to consolidate when he succumbed to the 
affection, at that time endemic in the ward. Billroth quotes a 
similar case; and Prescott Hewett records a third in the Lancet 
for 1867. 

In another instance that I have seen, the pyaemia supervened 
upon a chronic otitis, accompanied by caries of the petrous bone. 
In all these cases, metastatic abscesses were formed in the lungs. 

The second lesion that may be found in pyasmic autopsies is 
phlebitis. Billroth observed it twenty-eight times in eighty-four 
cases. As is well known, it is to phlebitis that Berard ascribes all 
the phenomena of purulent infection. The apprehensions of 
danger from this cause have been much diminished since Virchow 
has shown that the coagulation of blood in the veins is not its 
consequence but its cause, and that irritation directly applied to 
empty veins inflames the external coat, but leaves the inner 
tunic untouched. The inflammation of the inner coat is always 
a consequence of the softening of the coagulum that has formed 
in the cavity. 

This softening, or suppuration, as it has been called, takes 
place in two ways: ist. By the molecular disintegration of the 
fibrin. 2d. By the penetration into its mass of pus cells, or white 
blood-corpuscles, that have wandered from blood-vessels or from 
purulent collections in the neighborhood of the thrombus. 
Hueter, in his chapter, in Billroth and Pitha's Surgery, does not 
hesitate to admit this penetration, and considers it proved: (a.) 
By Cohnheim's experiments on the capacity of white blood- 
corpuscles to traverse the walls of capillaries and blood-vessels. 
(b.) By those of Recklinghausen, published in the Archiv of 
Virchow, and which show the contractility of pus cells, and of 
cells of connective tissue, (c.) By the experiments of Bubnoff, 
recorded in the Centralhlatt, of 1867, there has been directly 
observed the passage into the thrombus of pus cells that had 
previously taken up granules of cinnabar. In this connection we 
may inquire whether the presence of the granules did not com- 
municate a force of impulsion to the cells that they otherwise 



1 88 Mary Putnam Jacobi 

would not have possessed; and whether, therefore, pus cells that 
had become granular by commencing decomposition, would not 
be able to penetrate where others were shut out. 

When, by the medium of a phlebitis, inflammation may be 
propagated from the wound to tissues of vital importance, the 
softening of the clot may prove immediately fatal. In the 
Archives General es for 1871, Reverdin has pointed out that in 
anthrax of the face, inflammation of the facial veins may extend 
to the sinus of the dura mater, and excite a fatal meningitis. 

Except in such special circumstances of contiguity, phlebitis 
remains a purely local affection, not only in such typical cases as 
that of inflamed varicose veins, but also in others where it seems 
to substitute itself for a general disease. Thus, during an epi- 
demic of so-called puerperal fever, the patients affected with a 
well-defined metritis, or phlegmasia alba dolens, generally escape 
peritonitis or septic infection. Even the phlebitis that seems to 
have been generated by transport of pyrogenic material from a 
distant wound, may result in recovery, without signs of infection. 
I have seen one case where the extirpation, for cancer, of a mam- 
mary gland, was followed by phlebitis of the right leg — a real 
phlegmasia alba dolens, which retarded, but did not prevent 
recovery. So marked is the opposition between local adhesive 
phlebitis and pyemia, that Sedillot treated incipient cases of the 
latter disease by cauterization over the veins leading from the 
wound, for the purpose of exciting inflammation and an effusion of 
plastic material that should erect a barrier against the absorption 
of putrid substances, or, as Sedillot maintained, of pus. 

When the fibrinous coagulum remains hard, and obliterates 
the vein, no phlebitis ensues, as may be seen in ordinary varicose 
veins, or in the inopexia of cachectic diseases. The inflammation 
of the inner coat of the vein, as I have said, only occurs when the 
process of softening of the clot has extended the cavity first hol- 
lowed out in its centre, to the membrane limiting its periphery. 
It is infinitely probable that this process, which causes the phlebi- 
tis, is itself the cause of accidents of which the phlebitis is only an 
incident, because, on the one hand, these accidents coincide with 
the softening of thrombi, when little or no phlebitis exists ; on the 
other hand, there are very rarely accidents with a less degree of 
softening, and a very intense degree of phlebitis. 

The question of the influence of phlebitis in pyaemia resolves 



Pathogeny of Pyaemia and Septicaemia 189 

itself, therefore, into two others: ist. The formation of thrombi; 
2d. Their disintegration. 

Now it is extremely noticeable that many of the circumstances 
which favor the development of thrombi are precisely those 
which seem almost essential to the development of pyaemia. As 
Weber observes, since every traumatism involves a solution of 
continuity of veins, and since this is necessarily followed by a coa- 
gulation of blood in their interior, the formation of thrombi is a 
necessary consequence of every wound. But in superficial 
wounds of the soft tissues, the vessels are small, and easily obliter- 
ated at their extremities. When larger vessels are torn, one of 
two things happens: Either the vessel flattens together above the 
clot, obliterating its extremity, and then the thrombus never pro- 
jects into a free cavity; or the clot is prolonged as far as the near- 
est collateral vessel, and its extremity floats free in the stream, 
and in a space larger than its own diameter. When this last 
occurs in arteries, as is normally the case after hgature, no harm 
results, because the stream of blood is not coming from the 
collateral, but passing down into it, and if any fragments are 
separated from the fibrinous clot they must be carried down to 
another point on the periphery of the vascular system. But 
in the case of a vein the conditions are reversed; the collateral 
current comes from the periphery, strikes the floating end of the 
coagulum, breaks off a fragment, and carries it towards the heart 
and lungs. 

Of the conditions which favor the distintegration of the throm- 
bus, the first, therefore, are those which expose its free end to be 
broken off mechanically. These conditions are two : length of the 
coagulum, and such a structure of the tissue surrounding the 
veins as is opposed to their collapse. 

The length of the coagulum is increased: ist. By whatever 
increases the amount of fibrin in the blood, or render its circu- 
lation sluggish, as abundant haemorrhage, exhaustion from 
previous disease, privation, or old age. Weber attributes the 
rarity of true purulent infection among children to the activity of 
their circulation, which restricts the formation of thrombi. 2d. By 
the absence of valves in the veins. 3d, By the sudden sup- 
pression, through amputation, of an extensive vascular territory. 

The two latter conditions are presented by the veins in the 
long bones, the last especially after amputation of the thigh, 



I90 Mary Putnam Jacobi 

where, as is known, the Hability to pyaemia is at its maxi- 
mum. 

In osseous tissue, and especially in that of the long bones, is 
also found the second general condition favoring long coagula, 
namely, a structure that prevents the veins from collapsing. 
Lining the pores of the bones, they are necessarily maintained dis- 
tended, and this circumstance, which has been wrongly supposed 
to imply such gaping open into the wound as should permit the 
direct entrance of solid particles, really favors the formation 
of lengthy coagula, with all their consequences. The same condi- 
tion may be presented by the sinuses of the uterus when that 
organ fails to contract sufficiently after parturition. Here again 
are no "open mouths," but tortuous vascular canals, in which 
collateral currents meet and cross each other in every direction, 
filled with loose fibrinous clots that offer media for diffusion, and 
are liable to disintegration. 

The circumstances that favor the disintegration of the clot 
throughout its mass, constitute the second class of conditions 
which render thrombi dangerous. 

1st. First among these is the osteo-myelitis, which we have 
already noticed as so generally existing in fatal cases of pyasmia. 
The local activity of the circulation, uncompensated by sufficient 
force in the central part of the system, on the one hand determines 
serous effusions into the clots; on another, creates collateral 
currents ready to carry down stream the fragments resulting 
from the disintegration. This effect is added to that proper to 
the inflammation itself. 

2d. The softening of the clot is favored by the penetration 
into its mass either of pus cells already effused elsewhere; or of 
white corpuscles directly passing from the neighboring blood- 
vessels ; or, finally, of putrid liquids. We have noticed that the 
penetration of pus cells, which could not in any wise be considered 
a phenomenon of absorption, would be probably favored by their 
granular and angular condition ; and as this is peculiar to decom- 
posing pus, the influence of the latter may be in part explained. 
As to the white blood-corpuscles, with which we have seen that a 
certain proportion of pus cells may be identified, the most com- 
mon condition of their transudation is their previous stasis in 
capillaries, which has long been known to be one of the initial 
phenomena of inflammation. The well-demonstrated influence 



Pathogeny of Pyaemia and Septicaemia 191 

of intense local inflammation upon the development of pyaemic 
accidents, is thus in part accounted for by the penetration into 
the interior of thrombi of pus cells existing in the neighborhood. 
When such elements come from the tissues surrounding the 
thrombus, they penetrate it in virtue of the contractility demon- 
strated by Cohnheim and Recklinghausen. But, if they ever 
come from the surface of the wound — that is, penetrate from 
without inwards — they are diffused like other solid particles in 
the liquids which hold them in suspension. 

Since, after the closure of the lymphatics, there are no open- 
mouthed vessels gaping into the wounds, and consequently the 
absorption of pus as such is impossible, this diffusion from the 
surface of the wound is regulated by the general laws of diffusion. 
Thus it will be greater when there is a stronger pressure without, 
such as may be exercised by tissues rendered tense by inflam- 
mation or by fibrous aponeuroses, and when this is combined with 
a diminution of the pressure within, as by a lowered tension in the 
blood-vessels. A liquid diffuses more easily when it is less dense, 
and especially when it contains less colloid or albuminous sub- 
stances. Hence the thin sanious fluids first formed on wounds may 
be expected to diffuse more readily than thick pus, rich in 
albumen; and this corresponds to the fact already noticed, that 
septicaemia precedes the formation of pus, and seems due to toxic 
substances more diffusible. A granulated condition of the pus 
cells may favor their penetration. Finally, according to Sachs, 
the protoplasma of cells has a tendency to retain the solid parti- 
cles of liquids that diffuse into them, so that these grow less and 
less dense as they traverse successive layers of cells. With each 
decrease of density, or diminution of solid particles, the diffusing 
power is heightened, and the fluids that have once traversed the 
outer barrier of tissues, pass with continually increasing rapidity 
towards the interior of central canals or vessels. The ultimate 
action, therefore, would almost necessarily be exercised by the 
fluids. 

The fluid invariably present in cases of purulent infection, 
and added to the ordinary traumatic fluids generating septicaemia, 
is pus. From the numerous experiments that have been made 
by the direct injection of pus into the veins, certain facts may be 
considered as proved, ist. A single injection of fresh pus causes 
a temporary rise of temperature, but no other inconvenience. 



192 Mary Putnam Jacobi 

2d. This same rise of temperature may be induced by the separ- 
ate injection of either pus globules or purulent serum. 3d. The 
injection of purulent serum holding inert solid powders in suspen- 
sion, will determine the formation of pulmonary ecchymoses and 
infarcti if the serum be fresh; of pulmonary abscesses if it be 
beginning to decompose; of septicaemic symptoms and visceral 
gangrene if it be entirely putrid. 4th. The repeated injection 
of fresh pus at inteivals of two or three hours will produce metas- 
tatic abscesses according to Sedillot; but according to Billroth, 
who repeated these experiments, only a rise of temperature some- 
times, external suppurations, and occasionally pulmonary ecchy- 
moses. 5th. Finally, the injection of putrid pus will determine 
a violent septicaemia, with patches of visceral gangrene, and, 
in a concentrated form, is one of the most violent poisons 
known. .012 of the dried residue is sufficient to kill a small dog. 

The entrance into the economy of pus or of some of its ele- 
ments, would seem, therefore, to act in one of three ways: ist. 
As a medium for the diffusion of solid particles, which would 
block up the capillaries of the lungs, and thus form infarcti, 
according to the theory of embolism. These solid particles 
could not, however, be the pus globules themselves, because, in 
clinical conditions, these could never penetrate into the blood 
except in very small quantities, and a single injection of much 
larger quantities of fresh pus will not produce such effects. 
2d. The pus may be supposed to act by a peculiar alteration of 
the blood, such as occurs by repeated injections at short inter- 
vals. 3d. Finally, it may act as a putrid fluid, but endowed 
with toxic properties of peculiar intensity. 

The theory of embolism, invoked for the explanation of 
metastatic visceral abscesses, has, as every one knows, been 
successfully applied to the pathogeny of cerebral and pulmonary 
apoplexies; and there is no need in this place to enter upon its 
details. That the ecchymoses determined by the injections of 
fresh purulent serum and inert powders, represent the initial 
lesion of metastatic abscess, is rendered probable by the frequent 
clinical coexistence of the two, together with that of all the 
intermediate stages between them. Thus, in an interesting case 
of acute pyaemia, laid before the New York Pathological Society 
by Dr. Janeway, the lungs, liver, spleen, kidneys, and, extremely 
rare circumstance, even the heart, are said to be studded with 



Pathogeny of Pyaemia and Septicaemia 193 

"minute white spots surrounded by a red areola," evidently 
metastatic abscesses. The first stage of such abscesses was 
represented in the lungs by numerous nodules of pulmonary 
apoplexy; the last, at the apex of the heart, by two small cavities 
entirely filled with pus. 

But the progress of such infarcti towards suppuration, 
which is the characteristic fact of clinical pyaemia, and which is so 
difficult to reproduce in experiments, implies the addition of some 
other element to that of embolism ; for ordinary infarcti do not 
suppurate, but undergo the fatty or cheesy degeneration. In 
pyasmia, therefore, either the embolus, or the liquids with which 
it is impregnated, or both, must be possessed of peculiar proper- 
ties, and to them must be due the lobular inflammation of the 
lungs, and the suppuration in which it so rapidly terminates. 
This local inflammatory property may be considered identical 
with the general pyrogenic action that these same fluids exercise 
on the blood, and both depend on the accelerated metamorphosis 
of tissue and consequent generation of heat due to rapid chemical 
combinations. 

Diffused suppurative inflammations are, therefore, un- 
questionably the proximate cause of visceral metastatic abscesses ; 
and Ranvier, in his recent paper already alluded to, considers 
them sufficient explanation, without any necessity for the inter- 
vention of embolism. This distinguished microscopist declares 
that he never found the small vessels surrounding the abscesses to 
be obstructed; but on the contrary, during the ascending period 
of the abscess, they were always gorged with blood. These 
negative facts prove nothing, however, against the former exist- 
ence of capillary embolics, which disappeared in the midst of the 
vascular afflux their mechanical and chemico-vital irritation had 
determined. At all events, these inflammations which M. Ran- 
vier shows to be nodules of catarrhal pneumonia, with prolifer- 
ation of epithelium, are very different from the diffused patches 
of congestion or gangrene determined by the injection of putrid 
matters, whether these be purulent or non-purulent. In the 
latter case the effect on the general mass of the blood overpowers 
the local effect on special groups of capillaries. The lesions, those 
of septicaemia, resemble those of typhus, while the catarrhal 
pneumonia of pysemia resembles that induced by injection of 
solid powders into the bronchial tubes. The peculiar relations 



194 Mary Putnam Jacobi 

of the capillary net-work of the lungs to the circulation, net-work 
which must necessarily be traversed by any solid particles circu- 
lating in the blood; the coincidence in pyaemia, of such conditions 
as render the circulation of such particles highly probable; the 
almost universal localization of pyaemic abscesses in the lungs 
where Billroth found them in seventy-nine out of eight-four cases; 
the coexistence of all grades of lesions intermediate, with ecchy- 
moses and infarcti, and completely formed abscesses; all these 
facts indicate that the first-named mode of the action of pus — 
that where it acts as a medium for diffusing solid irritative parti- 
cles — is one of the most characteristic, and that which chiefly dis- 
tinguishes it from non-purulent septic fluids. 

In the second place, the fact that repeated injections of pus 
will produce effects that cannot be determined by a single in- 
jection, imply that the pus may act by a previous special altera- 
tion of the blood again different from that of septicaemia. Ac- 
cording to Sedillot, the effect of repeated injections of pus is to 
accumulate its corpuscles in the blood, and thus block up pul- 
monary capillaries by a peculiar kind of embolism. But this 
could not be true in clinical cases, for there the pus is not injected 
directly into the veins, but its elements, if they penetrate into the 
circulation at all, are diffused gradually in too small proportions 
to cause mechanical obstruction.^ 

Billroth admits a multiplication of the white blood-corpuscles, 
and an increased tendency on their part to accumulate in the 
capillaries of the lungs, whence the metastatic abscesses. He 
thus explains both the excess of white corpuscles noted by 
Sedillot, and also the peculiarity of the action of pus, as dis- 
tinguished from that of septic non-purulent fluids. 

Perhaps it is not too hypothetical to connect this excess of 
white corpuscles with the tendency to purulent effusions in the 
splanchnic serous cavities and in the articulations. These do not 
depend upon inflammation, for that seems rather to follow than 
precede them; and they may be reabsorbed with a rapidity un- 
known in ordinary purulent arthritis. 

When the pus is putrid it acts like putrid fluids, and deter- 
mines not pyaemia, but a septicaemia of peculiar malignancy. 

' M. Demarquay has recently performed some experiments, considered 
to prove that such penetration does take place. See Archives Cenerales for 
December. 



Pathogeny of Pyaemia and Septicaemia 195 

The poison generated in pus, therefore, seems to be much stronger 
than that of other fluids. 

Having passed in review the notable differences that exist 
between septicaemia and pyaemia in regard to their symptoms, the 
time and mode of their invasion, their anatomical lesions, and 
their reproduction by experiment, we are led to inquire whether 
these differences depend upon the operation of different poisons, 
or of the same poison operating in different conditions. The 
second doctrine is most emphatically affirmed by M. Verneuil in the 
recent discussion at the French Academy. He declares that pyaemia 
or purulent infection is to be regarded as an accidental compli- 
cation of a general disease, septicaemia, which in a mild form, at 
least, exists necessarily in the case of every open wound. Septi- 
caemia depends upon the absorption of sepsine, generated in the 
traumatic fluids; pyaemia occurs when this sepsine impregnates 
emboli that, carried to the lungs, form metastatic abscesses, of 
which each becomes a new focus of infection. 

The term sepsine, invented by Bergmann and adopted by 
Verneuil, represents the unknown quantity existing in purulent 
or putrid liquids that gives them their peculiar pyrogenic proper- 
ties. Great efforts have lately been made to isolate this hypo- 
thetical substance. Panum and Hemmer have shown that it 
exists partly in the serum of the pus, partly in the filtered globules. 
It is not volatile, and cannot be distilled from pus, but remains 
behind in the dry residue. An aqueous extract of this residue is 
toxic, and, moreover, will diffuse through animal membranes, and 
communicate its properties to pure water on the other side. This 
diffusibility is an eminent characteristic of the "sepsine," so 
called; and in virtue of it Bergmann claims to have isolated the 
toxic principle from many others with which it was associated, 
including inorganic matters, albuminous substances, and leucine. 

Direct experiments with a number of substances, as various 
salts of ammonia, sulphide of carbon, solutions of leucine or 
tryosine, either produced no effect, or symptoms quite different 
from those of septic or purulent infection. With sulphide of 
ammonium alone, Weber, who employed much stronger doses 
than Billroth, obtained a notable rise of temperature and a septic 
inflammation of the intestinal mucous membrane. 

Until the toxic principle in the two cases shall have been 
isolated its unity cannot be considered proved. In the mean time 



196 Mary Putnam Jacobi 

the following facts speak in favor of the existence of two poisons 
analogous to each other, but not identical. 

1st. That non-purulent liquids, holding solid particles in 
suspension, do not determine the same lesions as purulent serum 
that has first been filtered of its globules and then associated with 
inert powders. 

2d. That the train of symptoms which occur after the estab- 
lishment of suppuration, are not merely different in degree, but in 
kind from those which have preceded it. 

3d. That pus exercises an action apart from that determined 
by its putridity. 

4th. When pus is putrid it is a more violent poison than other 
putrefying traumatic fluids. Clinically the presence of putrefy- 
ing pus is associated with the mixed disease, septico-pyamia, the 
most fatal of all surgical affections. 

5th. The conditions of the diffusion of pus have been shown 
to be different from those of primitive septicaemia. 

Independently, however, of the probability of some special 
toxic agent in pus, which gives a peculiar character to pyasmia, 
the existence of metastatic abscesses introduces new compli- 
cations by multiplying the foci of infection. From each abscess 
new pyrogenic material is continually being thrown into the 
blood, and when the abscess is situated in the lungs, the material 
that has been formed there is probably peculiar, on account of the 
peculiar exposure to air to which it has been submitted. 

The dependence of the characteristic march of pyaemia upon 
metastatic abscesses, is shown by the insidious invasion of its 
symptoms at this moment of their formation, and by its gradual 
intermittent progress in proportion to their successive evolution. 
Hence the initial chill after the subsidence of traumatic fever; 
hence the increasing violence of the chills as the visceral suppura- 
tions become more numerous; hence the peculiar danger of pul- 
monary abscesses so much greater than that of even pyasmic 
abscesses formed in external cellular tissue. 

On the other hand, it is unquestionable that the violence of 
pyaemia is not invariably in proportion to the number of pul- 
monary abscesses; and that in certain cases where the first 
symptoms have coincided with external suppurations, the 
abscesses found in the lungs after death are evidently of recent 
formation. I have seen several such cases, in which, even though 



Pathogeny of Pyaemia and Septicaemia 197 

the final catastrophe be attributed to the pulmonary complication, 
yet it is unquestionable that pyasmia must have been prior to it. 
In these cases it is impossible to avoid belief in the direct action 
upon the blood of the elements of pus derived from the surface 
of the original wound. 

The prophylaxis of septicaemia is more easily attained than that 
of pyaemia, because the conditions upon which septic poisoning 
depends are less peculiar than those of pyaemia. There is no 
special anatomical condition of the wound, such as exists when 
bony tissues are involved. The system is capable of tolerating 
the absorption of a certain amount of septic material, and when, 
from the extent of the traumatism, there is an excess of dead 
tissue, this may be removed by surgical interference. The great 
indications in the prophylaxis of septicaemia are ist, to prevent 
the devitalization of new tissues; 2d, to prevent the exposure of 
tissues thus devitalized to the action of infusoria, or animal germs, 
the agents of putrefaction. 

The first indication is pre-eminently fulfilled by purification of 
the air which the patient is compelled to breathe. This is effect- 
ual, not on account of any direct action upon the wound, but by 
maintaining the nutritive powers of the blood and its consequent 
action upon tissues whose vitality is threatened. So long as this 
vitality is maintained, the development of microzymes is to be 
little dreaded. 

The second condition is only completely fulfilled when air is 
completely excluded from the wound, and with it, on the one 
hand atmospheric germs, on the other the oxygen necessary to 
the development of animal microzymes. Air is nearly excluded 
when a wound is enveloped in an atmosphere of carbolic acid, and 
to such exclusion must be largely attributed the favorable result 
of such treatment. Occlusion, either by this so-called "anti- 
septic" or by mechanical means, may prevent the decomposition 
of traumatic fluids; but when this has once set in, nothing will 
arrest it, not even the destruction of the germs which may have 
been its cause, as we have seen, these die of themselves in the 
putrefying fluids whose putrefaction they have determined. 
Hence a treatment directed to their destruction would be worse 
than superfluous, if it led to neglect of the great indication in the 
prophylaxis of this stage, removal of the traumatic fluids from 
beyond the reach of absorbents. 



198 Mary Putnam Jacob! 

The greater facility with which this removal may be effected 
in the case of wounds of soft tissues explains their greater im- 
munity from danger, and the far greater success of carbolic acid 
in their treatment. The septicaemia that may occur in the course 
of such wounds, depends upon the absorption of non-purulent 
decomposing fluids, and its intensity is in proportion to their 
mass. When the fluids already formed have been carefully 
washed away, the use of carbolic acid, that will not, by the 
ordinary methods, prevent decomposition, nevertheless restrain 
it, and hence reduce septicaemic accidents to a degree of intensity 
bearable by the economy. It is in these cases that the effect of 
good atmospheric hygiene is so apparent, by preventing the 
devitalization of new tissues. The most dangerous degrees of 
septicaemia may be averted, and its worst form, hospital gangrene, 
be entirely banished from hospital wards. 

But pyaemia is connected with much more complicated condi- 
tions, many of which are entirely beyond the reach of carbolic 
acid. It depends on the presence of a fluid that, once secreted, 
decomposes with peculiar facility, seems to generate a poison 
of peculiar intensity, and expose the products of its decomposition 
to absorption at a moment that the power of absorption is at its 
maximum. It has been shown to act, not merely in virtue of 
such decomposition, like all putrid fluids, but by a special effect 
on the blood, and by a special connection with the thrombi 
blocking up the veins surrounding the wound. While the poison 
of septicaemia is principally absorbed by the lymphatics, that of 
pyaemia passes almost exclusively by the veins, either those in the 
bones, or those newly developed in the granulations of the wound. 

This poison is therefore contained in inaccessible canals, and 
carbolic acid has as little effect upon it as it would upon an abscess 
in whose cavity it had been injected and shut up to mix with its 
contents. A comparatively minute proportion of purulent 
poison is capable of inflicting all the injury possible, so that 
great diminution of the mass of toxic material has very much 
less effect on the development of pyaemia than on that of septic- 
aemia. The control must be complete, or it is useless, and it 
must be exercised not merely in the general hygienic conditions 
to which the patient is submitted, but still more, over the local 
conditions peculiar to the anatomical nature of his wounds. 

From this predominance of local conditions, pyaemia is, as 



Pathogeny of Pyaemia and Septicaemia 199 

might be expected, no exclusively hospital disease. Billroth 
asserts that it is as common in private practice as in hospitals, 
only when a death occurs that cannot be explained by hospital 
miasms, it is attributed to gastritis, or other accidental complica- 
tion. Mr. Callender, in the fifth volume of St. Bartholomew's 
Hospital Reports, shows that although the mortality of city 
patients operated on in city hospitals was higher than that of the 
country, yet the mortality of country patients was the same, 
whether they were in large city hospitals, in small country 
hospitals, or even in average country practice. 

It follows that absolute exclusion of air from the wound is 
much more important in the prophylaxis of pyasmia than of 
septicaemia. The partial occlusion effected by incrustation with 
carbolic acid, is often sufficient for wounds of soft tissues. But 
for wounds involving osseous tissues, the apparatus employed by 
M. Maisonneuve at the H6tel-Dieu is much better adapted. 
Most American surgeons visiting Paris have had an opportunity 
of observing this method of treatment, but I do not know whether 
it has been introduced into this country. The moment that a 
limb is amputated, the stump is surrounded by a conical gutta- 
percha cap, whose rim fits air-tight to the skin. From the apex 
of this cap passes an India-rubber tube that connects with an 
aspirating pump. By means of the pump the liquids from the 
wound may be drawn off, and discharged by a second tube into a 
receiver. During the intervals, the elastic walls of the cap and 
tube coming from the wound, fall together so that no air is in con- 
tact with the suppurating surface. To dress the wound, the tube 
is detached from the pump, and connected with the tube of a bulb- 
syringe, in whose continuity is inserted a short piece of glass tub- 
ing, so that the operator may watch the stream of fluid he injects 
upon the stump, and be sure that no bubbles of air pass over. 
The detersive liquids employed are either tincture of arnica or a 
solution of carbolic acid. These, injected in a continuous stream 
on the stump, are allowed to flow off by a secondary tube, con- 
nected with that of the bulb-syringe. In this way the wound 
is dressed daily, without the least exposure to the air. The 
apparatus may also be used in cases of accidental traumatism, 
as compound fracture; but here it may be less efficacious, when 
the dead tissues have already been for some time exposed to the 
air. 



200 Mary Putnam Jacobi 

As far as my own observation extended, this apparatus 
5delded excellent results, and the principle upon which it is based 
seems certainly most rational. I am unable to tell why it is not 
adopted in other surgical wards than those of M. Maisonneuve. * 

' I found, after writing the above, an account of Maisonneuve 's apparatus 
in the fifth volume of the Practitioner. 



REPORT OF AN ADDRESS TO THE GRADUATING 

CLASS OF THE WOMAN'S MEDICAL COLLEGE 

OF THE NEW YORK INFIRMARY^ 

Woman's Medical College of the New York Infirmary. 
— The Commencement exercises of this College were recently 
held at Association Hall. 

Prof. Mary C. Putnam, M.D., delivered an address upon 
the true method in Medical Education. She brought out very 
clearly and forcibly the principle that the knowledge which is 
really to be of use to the physician must be that gained by his own 
observation, not that taken on the authority of books or lectures. 
From the beginning, therefore, the student should be taught 
to observe, to experiment, and to think, for himself. His chemis- 
try should be learned in the laboratory; his histology and physio- 
logy by work with the microscope and experimentation on 
animals; his diagnosis and therapeutics by study in dispensary 
and hospital of actual cases, for which, under proper supervision, 
he is made responsible. In this way, and in this alone, would his 
practical skill keep pace with his theoretical knowledge ; he would 
really know his subject, and not simply know about it. When 
called to a case of emergency he would be prepared, at once, and 
with a just self-confidence, to bring all his faculties to bear upon 
it — would think with his whole body, that had been trained for 
this very work, and not be driven in despair to his note-book or 
his library. Having once learned the true method of study, he 
could never become a routinist, but would hail every new case as 
a problem for fresh investigation. 

The speaker sketched a plan in which all the medical charities 
of our metropolis should be organized in a grand system for the 

' Reprinted from The Medical Record, 1872. 

201 



202 Mary Putnam Jacobi 

purposes of instruction. The students of the various schools 
would be divided into small classes for clinical work, each class 
under the immediate charge of a clinical clerk, and the whole 
under a central directory; so that wherever a case occurred of 
interest to a special class, the notification could immediately 
be given and the opportunity improved. 

Contrasting what ought to be done in this direction with the 
mode of instruction at present pursued in our schools, the Doctor 
characterized our lecture system as an enormous anachronism, a 
legacy of the times of mediaeval darkness, when original scientific 
study was a thing unknown, and the only fountain of learning was 
the wisdom of the ancients; when the business of the medical 
teacher was to give epitomes of Hippocrates and Galen, and that 
of the student to make and memorize his abstracts of these epito- 
mes. Now, fully as we realize the grave deficiencies of our 
colleges, we think she has here done them less than justice. 
Their professors do not, as a rule, content themselves with reiter- 
ating the theories of past centuries, or even of the past decade. 
They keep abreast of the times, and give the student the latest 
results of investigation, which cannot be found in his text-books, 
but must be sought in monographs and journals. True, there 
are exceptions, even in our own city; but we claim that they are 
exceptions to the rule. For this purpose, then — to announce 
the last revision of scientific theory, as well as the newest facts of 
observation, and, moreover, to present the grand outlines of a 
subject in the vivid and impressive way which no book can 
imitate — we hold that the accomplished lecturer has still a most 
important place to fill. We agree, however, that every fact must 
be made the student's own by practical experiment where this is 
possible; that he must be taught to test every theory in the 
crucible of his own reason ; and that the lectures are valuable only 
as they lead him to do so. 

The only reference to the recent change of curriculum in the 
Medical Department of Harvard University was the statement 
that laboratory work, formerly optional, was now compulsory. 
We think the stand taken by this school deserved a more cordial 
recognition. Its compulsory laboratory work extends not only 
to chemistry and gross anatomy, but also to microscopy and 
physiology. Its clinical instruction really deserves the name, the 
senior students being expected to diagnosticate cases, prescribe 



An Address to the Graduating Class 203 

their treatment, and present written reports of them, which are 
discussed before a "conference" of the class, presided over by a 
professor. This, and other similar features, we remember as 
prominent in the course many years ago. Taking the above in 
connection with the late gradation of studies through the three 
years, and the required attendance on recitations during the 
summer, we think the school goes far toward fulfilling Dr. 
Putnam's idea. A preliminary examination for matriculation, 
and an extension of the term of professional study to four years, 
are still, however, great desiderata. 

We have touched upon only a few points of this address, which 
was marked not more by its suggestiveness than by its earnest- 
ness, sometimes rising to eloquence. 



ON ATROPINE^ 

A LECTURE DELIVERED AT THE WOMAN'S COLLEGE OF THE N. Y. 

INFIRMARY 

1873 

Ladies : — In inaugurating this year's course of lectures, I must 
first point out to you a certain change that I have made in our 
programme; — a change which will cause it to differ materially 
from that of corresponding courses delivered at other schools 
in this city. 

Last year, imitating the system that I believe generally 
prevails in this country, the lectures on Materia Medica and 
Therapeutics were combined, and both attended by all the stu- 
dents, whether these had been studying one, two, or three years. 
On this account, students at the very outset of their career were 
compelled to listen to accounts of the remedial action of drugs, 
that their ignorance of pathology rendered completely unintelli- 
gible to them; and, on the other hand, others, preparing to 
graduate, were obliged to review details in the chemical and 
pharmaceutical history of medicines, when these, in comparison 
with the urgent interest offered by their therapeutical properties, 
could not but seem dull and unimportant. Moreover, such 
students, having passed through no preliminary training, were 
plunged immediately into one of the most complex and difficult 
studies in the entire range of human sciences — that of the action 
of drugs on the living organism in health and disease. A science 
that requires as basis a minute and comprehensive knowledge of 
physiology and pathology, was thus attacked by persons who as 
yet were only furnished with the most slender modicum of such 

» Reprinted from The Medical Record. 

204 



On Atropine 205 

knowledge. As a necessary consequence, the true complexity 
of the subject was ignored, and knowledge of the action of drugs 
resumed in a few bald formulas, whose simplicity, no less than 
their rigidity, rendered them entirely insufficient as guides in the 
labyrinth of therapeutical problems. 

As such system of instruction was illogical I have not hesi- 
tated to set it aside, though supported by so much example and 
precedent. This year, therefore, the course will be divided into 
two distinct sections. The first year students will be invited to 
the study of materia medica; to familiarize themselves with the 
properties of drugs in their natural and commercial condition; 
afterwards to trace them through their various pharmaceutical 
preparations, many of which they will have an opportunity of 
fabricating themselves. They will learn the origin, the botanical 
and chemical classification, the chemical constitution and physi- 
co-chemical properties of drugs, before attempting to rise to the 
contemplation of their properties in relation to vital organisms. 
By this means they will thus: ist, acquire certain knowledge 
which otherwise they are only assumed to possess ; 2d, be trained 
for the acquisition of other knowledge which they must in great 
measure miss, if they have not been previously prepared to 
receive it by exercise in simpler studies. 

The second and third year students will study, in a two years, 
course, the physiological action and therapeutical application of 
drugs. As far as possible each proposition will be illustrated by 
experiments made upon animals in our laboratory, or by the 
treatment of patients selected from our clinics. 

I will express the hope that, before long, our school will 
accept the standard of Europe, and create a chair of materia 
medica entirely distinct from the chair of therapeutics : that, fur- 
ther, each of the seven primitive chairs will be divided into an 
elementary and an advanced section. Until this is done, all 
medical education will remain elementary, and the very concep- 
tion of a superior education will continue to be ignored. 

I have selected atropine as the first subject of this year's 
studies, because the researches that have been made in regard to 
it afford a complete type of those that should be pursued in regard 
to every reputed remedial agent. It is necessary, ist, to observe 
the succession of phenomena produced by such agent after its 



2o6 Mary Putnam Jacobi 

introduction in a healthy organism; 2d, to analyze each of these 
phenomena to its ultimate elements; 3d, to compare the effects 
of the drug upon organisms involved in various morbid conditions, 
with the results obtained from such analysis. 

In the first place, therefore, we have to consider the general 
tableau constituted by the physiological effects of atropine . . . ; 
and the first phenomenon that demands analysis is the effect of 
atropine on the pulse. 

There is no doubt that atropine accelerates the pulse. But in 
regard to this acceleration we must ask the following questions : — 

1st. Is this acceleration immediate or secondary ? According 
to Harley and Meuriot, the pulse is immediately accelerated after 
the administration of atropine; this acceleration is indeed the first 
effect produced. According to Schroff, Posner and Nothnagel, 
the pulse is first lowered, and afterwards accelerated. According 
to Bezold, the acceleration is immediate after subcutaneous 
injection, secondary after ingestion of the poison. In Bezold's 
experiments upon guinea-pigs and dogs, an acceleration of from 
14 to 48 beats frequently occurred during the first minute, or 
even quarter of a minute. In one dog, the pulse rose suddenly 
from 80 to 240 beats in a minute. In these cases the atropine had 
been injected into the facial or external jugular vein. 

Harley's observations are less reliable, because not made until 
ten minutes after the injection. 

In the three cases where we tested the action of atropine on 
human beings before your eyes, we observed a fall of the pulse 
within ten minutes. In the first case the patient was a delicate, 
lymphatic, but not nervous woman, to whom one-fiftieth gr. of 
sulph. atropiae was given by the mouth, the pulse then being at 
96, probably from some emotional excitement. In ten minutes 
the pulse had fallen to 80, and remained at 80 to the end of an 
hour, notwithstanding the occurrence of other symptoms of 
atropism, a slight flushing of the face, dryness of mouth and 
throat, and very slight dilatations of the pupils. In the second 
case the subject was a rather robust woman in good health. 
The pulse being at 80, one-fiftieth gr. sulph. atrop. was given by 
subcutaneous injection. In seven minutes the pulse had fallen 
to 68. In fifteen minutes came a dryness of the throat and slight 
giddiness. In twenty minutes the pulse had risen to 104. This 
rise may have occurred at fifteen minutes, as at that time the 



On Atropine 207 

pulse was not examined. In the third case, after hypodermic 
injection of ^ grain, the pulse fell in five minutes from 92 to 80, 
in 10 minutes rose to 100, in 20, to 104. 

You see, therefore, that both these cases contradict Bezold's 
statement, that the acceleration is always immediate after sub- 
cutaneous injection, and always secondary after ingestion; for 
in the cases of injection the acceleration, which was notable, was 
preceded by a marked diminution, and in the case of ingestion 
the pulse fell, and did not again rise. But in this case the subject 
belonged to a class that we shall find, for reasons to be hereafter 
noticed, is rather insusceptible to the action of atropine, and 
therefore the dose was too small. The other cases, on the other 
hand, fairly represent habitual conditions. This initial fall of the 
pulse is more certain to occur in human beings than in dogs, 
whose cardiac susceptibility to atropine is very great. It is also 
to be expected from subcutaneous injection rather than from an 
injection into veins. This phenomenon is too transitory to be 
of any value therapeutically, but physiologically it is extremely 
interesting, in connection with another atropine effect of which we 
shall presently speak, — I mean the contraction of the small 
arteries. 

2d. At what doses does atropine determine an acceleration 
of the pulse ? 

On this point there is unanimous testimony. The heart's 
action is accelerated by small doses, and slackened, on the con- 
trary, by large. In guinea-pigs, from 0.0005 to 0.02 accelerated 
the heart from 4 to 12 beats in 15''; while 0.05 lowered the pulse 
in one case from 70 to 44, in another from 80 to 58. With o.io 
the pulse first slackened, then stopped in about a minute (Be- 
zold).^ In the horse, with one-twelfth of a grain, there was 
acceleration of the pulse 10 beats in 35 minutes; with one-sixth, 
acceleration of 24 beats in 1 7 minutes ; with \, acceleration of 56 
in 12 minutes: and this was the maximum acceleration obtained. 
With I grain it was 42 beats in 12 minutes, and with 2 grains 35 in 
15, or 37 in 20. Similarly on the dog, with -gV grain pulse rose 
from 120 to 300 in 14 minutes; and -^ and -^V grain produced the 
same effect; but with ^ the pulse was 400 at the end of i^ hours. 
In man there is said to be an acceleration of 20 to 25 beats with 
Y^ or ^V grain; 20-60 beats with ^ grain, 20-70 with :^, and 

' Ueber die Physiol. Wirk. des A tropins. Leipzig, 1867. 



2o8 Mary Putnam Jacobi 

only 30 with ^jV of a grain (Harley). ' Meuriot noticed an acceler- 
ation of 84 beats in 90 minutes after an injection of o.ooi . Never- 
theless, with toxic doses, the pulse remains extremely frequent 
until an advanced period of the coma. In Behier's case, ^ where 
an old man of 75 had taken 0.013 of sulph. atropiae, the pulse 
was 108 in three hours, at the beginning of profound coma, and 
rose afterwards and beat at 120 all night, and until return of con- 
sciousness. In a case quoted in Amer. Jour. Med. Sciences for 
1866, from Schmid,^ after ingestion of ^ grain of atropia, and 
during period of excitement, the pulse was 130. On the other 
hand, in the famous case of Dr. Angelo Poma,"" when a profound 
coma had set in 2^ hours after the ingestion of f 5 j- of solution 
of extract of belladonna, the pulse was extremely slow. In 
several other cases of poisoning it is recorded that the pulse was 
weak and depressible, though the number of pulsations is not 
given. In Lee's cases of poisoning with the analogous mydriatic, 
stramonium, 5 the pulse was from 100 to 150 in the two men 
patients, who were comatose when treatment commenced; and 
140 in the woman, who was in a state of maniacal excitement 
resembling delirium tremens. The pulse only sinks immediately 
and permanently when injected into the jugular vein, a condition 
that evidently is never reproduced in man. 

By ingestion or subcutaneous injection, and after the initial 
slight fall, the pulse is therefore always accelerated; and this 
acceleration, though not in exact proportion to variations of 
physiological doses, is excessive in those doses where it will 
ultimately or rapidly be succeeded by slackening. (See also 
Schroff^ and Meuriot.'') This fact is important to remember, in 
interpreting certain details of the reactions of belladonna in cases 
of opium poisoning. By it we also test the value of the assertion 
made by Lemaitre,^ and supported by another, quoted by him 
from Leusana, ' that the effect of atropine upon the pulse is only 
shghtly appreciable. 

" Old Vegetable Neurotics. London. 1869. 

' Union Afedicale. 1863. ^ Klin. 

* Gaz. Hehdomadaire. 1863. ^ Amer. Jour. Med. Science. 1862. 
6 Schmidt's Jahrhiicher, Bd. 76. 1852. 

^ Meuriot. These sur la Belladone. Paris, 1 865. 

* Archives Generalei. 1865. 
9 Union Medicale. 1851. 



On Atropine 209 

3. How is the pressure in the arteries affected during the 
atropine acceleration of the pulse? Marey has formulated the 
following law: — "The frequency of the pulse, or of the cardiac 
contractions, is in inverse relation to the degree of arterial ten- 
sion." It has been said, on the other hand,^ that Ludwig and 
Thiry have formulated another law, precisely the reverse of this : 
"The frequency of the pulse increases with the arterial tension." 
In both cases the arterial tension is taken as the point of departure, 
and its rise or fall declared to be a cause of the acceleration of the 
heart's action. This quotation, however, is not quite incorrect. 
According to the exposition of Ludwig's views, made in a memoir 
of Bezold, ^ and also in another of Pokrawsky, after an increase 
of the blood-pressure, the pulse was sometimes quickened and 
sometimes slackened. This, whether the increased pressure was 
determined directly by closure of the cceliac and renal arteries, 
or indirectly by irritations of the spinal cord or splanchnic 
nerves. Thus Ranke, who admits that an acceleration of the pulse 
takes place when the arterial pressure is increased, observes that 
it occurs likewise when this is diminished, but when the force 
of the heart is diminished even more rapidly than the resistance 
in the arteries. ^ 

It is evident that arterial tension may be increased, either 
when more blood is thrown into the arteries by greater force of the 
heart's action or when an obstacle exists to its efHux. An agent 
that, like cold, excites the active contractility of the small arteries, 
by accelerating the peripheric circulation, necessitates the accler- 
ation of the heart's action. The tension of the blood-vessels 
rises, but the rise is the consequence, and not the cause, of the 
quickened pulse. With any condition that weakens at once the 
blood-vessels and the heart, as fever, or the action of certain 
narcotics, the tension will be lowered, yet the heart accelerated, 
while the vessels are passively dilated. Both the acceleration 
and the lowered tension depend on the insufficiency of the cardiac 
contractions. With bromide of potassium the small arteries are 
completely constricted, the tension raised (?), and the pulse 
lowered. With atropine, the arteries are partially constricted, 
the tension raised, and the pulse accelerated. Only at the very 

' Chauvet De la Circulation Capillaire. Theses de Paris. 1869. 

' Untersuchungen ilber die Herz und Gefdssnerven der Sdugethiere. 1867. 

^ Lehrbuch der Physiologie des Menschen. 1872. 



210 Mary Putnam Jacobi 

beginning the pulse falls, and this before any effect has been 
produced on the small arteries. The acceleration of the pulse 
coincides with acceleration of the local circulation, from the 
increased active contractility of the arteries. As this local 
acceleration is sufficient to compensate the degree of obstacle 
caused by the constriction, the rise of tension cannot be explained 
by that, but by the rapidity with which the arterial system is 
filled. 

In Meuriot's experiments upon man with atropine the 
line of ascent in the sphygmographic trace (percussion stroke of 
Mahamed') remained vertical, but was not so high as normal. 
This would indicate that the arterial tonicity was increased, 
while the heart had not lost any of its vigor. At the same time, 
the line of descent was not separated by any appreciable interval 
from the upper stroke, showing that no obstacle existed to the 
efflux of blood into the capillaries. This rise in the tension was 
first noticed in 15 minutes after injection of o.ooi. (y^^ gr.) and 
had increased in 30 minutes, the pulse quickening at the same 
time. In one observation, where 0.012 were injected and the 
trace taken in 40 minutes, the vertical up-stroke had fallen still 
lower, and there was moreover a rounded summit, as if with this 
dose and at this time, the efflux of blood was somewhat obstructed . 

When the tension in the carotids was measured in dogs by a 
haemometer, the pressure rose with a subcutaneous injection of 
from 0.005 to 0.05 sulph. atropine (j-g^ to y^ gr.). This was the 
limit within which the pulse rose. With injection of o. 10 (i§ gr.) 
the pulse and the arterial pressure fell together. 

Similar experiments by Bezold gave similar results. In the 
cases already mentioned, where the dose administered caused an 
acceleration of the pulse, it generally caused an increase in the 
blood pressure also. But in one case (Guinea-pig) this sank from 
92 to 72 millimetres during the injection, and did not recover 
its original level until 30 minutes after, although the pulse was 
slightly accelerated. In another, where 0.30 were injected into 
the facial vein of a dog, the pulse rose in I minute after the 
injection from 60 to 192; but the pressure in the carotid sank 
from 140 to 20. In this curious experiment, the dog was killed 
by successive doses of atropine (he received in all 0.80); — arti- 
ficial respiration was practised and the abdomen opened. This 

' Med. Times and Gaz., 1872. 



On Atropine 211 

operation generally lowers arterial tension, but in this case it rose 
to 30 (having sunk to 5), while the pulse beat 168 times in the 
minute. 

From these experiments it appears, that with the moderate 
acceleration of the pulse during the first stage of atropine the 
pressure rises; — with the excessive acceleration of sudden toxic 
doses, of coma; — of ultimate paralysis, in a word, — the pressure 
sinks. We think that it may be thence inferred, that in atropin- 
ism the pulse is not accelerated because the tension is increased, 
but that the tension is increased because the pulse is accelerated, 
the heart at the same time retaining its vigor, and thus, in a given 
Lime, throwing more blood into the arteries. In the paralytic 
stage the heart contracts as rapidly, but with great feebleness; 
at the same time also there is paralytic widening of the blood- 
vessels, so that a double influence exists to lower the tension. 
These details are of special interest, in comparing atropinism with 
the results of section and galvanization of the pneumogastric 
nerve. 

4th. Thus we see that the heart's action is accelerated by 
atropine in extremely small, i. e., therapeutical doses; that this 
acceleration occurs immediately in dogs, after a slight initial 
diminution in man, and is accompanied by increased arterial 
tension. Upon what does this acceleration depend? The pulse 
is accelerated, — ist, when the muscular fibre of the heart is di- 
rectly stimulated by a greater afflux of blood, itself determined 
by increased respiratory movements. 

2d. Similar direct stimulus is felt by the intracardiac ganglia, 
controlling the rhythm of the heart's movements. 

3d. Acceleration also occurs when the cervical sympathetic or 
cervical spinal cord from which it is given off is galvanized. 

It is well known that the modus operandi of this influence is 
the subject of a famous dispute, to which we have already made 
allusion. According to Bezold and Pokrawsky, ^ the influence is 
direct, and galvanization of the nerve acts immediately upon 
the muscular fibre of the heart to which it is distributed. Accord- 
ing to Ludwig and Thiry, the influence is indirect, and dependent 
upon variations in arterial tension. Galvanization of the sympa- 
thetic or of the cervical cord causes the contraction of whole 

' Ueber das Wesen der Kohlenoxyd Vergiftung. — Dubois und Reichert's 
Archiv, 1866. 



212 Mary Putnam Jacobi 

territories of blood-vessels, even those of the mesentery. This 
still occurs, when the cord is galvanized, after all the nerves going 
from it to the heart have been cut, and according to Ludwig, 
in that case the pulse is still accelerated. But Bezold and 
Pokrawsky affirm, on the contrary, that in this case the acceler- 
ation of the pulse is much less marked than when the nerves are 
intact. The contraction of the blood-vessels still occurs, but the 
direct stimulation of the heart is wanting. The three observers, 
however, it is seen, agree in ascribing a certain amount of acceler- 
ation of the pulse purely to the rise of arterial tension determined 
by constriction of the blood-vessels — contrary to the theory of 
Marey. According to Bezold's theory, if atropine stimulated 
the sympathetic in the heart, as it does in the small arteries, 
the heart would be directly accelerated, by stimulation of its 
accelerating nerves. According to the other theory, any stimu- 
lation of the cervical or cardiac sympathetic would merely rein- 
force that directly exercised upon the blood-vessels by the local 
contact of atropine. The only way to prove a direct influence 
upon the sympathetic is to isolate the heart by a section of 
the pneumogastric, and then administer the atropine. But the 
acceleration of the pulse after this operation is already so great, 
that such acceleration as might be produced by stimulation of the 
sympathetic would be entirely masked. It is certain that when 
atropine is injected after section of the pneumogastric, the 
acceleration of the pulse is not further increased. 

The constriction of the small arteries sometimes coincides 
with an accelerated, sometimes with a slackened pulse. Some- 
times, as in Ludwig's experiment, where the cervical cord is gal- 
vanized after section of the sympathetic nerves going to the heart, 
this constriction seems to be the only cause of the acceleration 
of the heart's action, and the acceleration is not very marked. 
Sometimes, as after administration of bromide of potassium, the 
small vessels are strongly contracted, but at the same time, 
the pulse falls. The same coincidence is shown in an ob- 
servation of Pokrawsky's. When carbonic oxide gas was in- 
jected into the veins or inhaled, the small arteries, stimulated 
by blood deficient in oxygen and too rich in carbonic acid, con- 
tracted: at the same time, the pulse and tension fell "from coin- 
cident irritation of the medulla and vagus." 

But the active partial contraction of the small arteries deter- 



On Atropine 213 

mined by atropine, with increased local circulation, is quite 
different from the complete contraction caused by bromide of 
potassium or carbonic oxide or carbonic acid gas. If the blood 
flows more rapidly at the periphery, the heart must contract more 
rapidly. Hence in this way the stimulation of the sympathetic 
produced by atropine would be one cause of the acceleration of 
the pulse. Whether there is also a direct stimulation of the 
fibres going to the heart we cannot consider at present as 
determined. 

4th. The most powerful means of acceleration of the heart's 
action is well known to be section or paralysis of the pneumogas- 
tric nerve; after this operation the pulse rises immediately to 
double and quadruple its previous speed. Now, the remarkable 
acceleration of the pulse that follows the injection of atropine 
can only be compared to that determined by section of the pneu- 
mogastric. It is also most noticeable in those animals, as dogs, 
upon whom section of the vagi produces the most marked 
effect on the pulse. The tension rises after atropine, as after 
section of the pneumogastric. As already noticed, if the pneu- 
mogastric be severed previously to the administration of atro- 
pine, the acceleration of the pulse is not further increased, as if 
the agent upon which the atropine usually acted had been 
suppressed by the operation. Finally, if the vagus be cut in an 
animal previously atropinized, galvanization of its peripheral 
extremity will no longer produce cardiac tetanus. The electrical 
excitability of the sympathetic remains intact. From these 
facts, we think the inference' is indeed justified, that atropine 
accelerates the heart's action, by partially paralyzing the pneu- 
mogastric nerve. 

At the same dose, however, atropine, as we have seen, has no 
appieciable effect on the respiration. Hence the main trunk of 
the pneumogastric nerve cannot be paralyzed, for in that case the 
respiration would be interfered with in the ordinary manner. 
Moreover, when the atropine is injected into the carotid, and 
sent towards the brain, the pulse is at first slackened, until time 
enough has elapsed for the poison to be distributed throughout 
the body, and reach the heart. But if it be injected in the jugular 

I Meuriot, Bezold, Botkin, loci cit. Conclusion contested by Harley; 
but it is difficult to see on what grounds. Huseman, on the contrary, indorses 
this view. 



214 Mary Putnam Jacobi 

vein, the acceleration is immediate, and much more marked than 
by ordinary subcutaneous injection. 

Hence we may infer that the atropine acts upon the cardiac 
peripheric extremities of the pneumogastric nerve, partially 
paralyzing them ; that this is the first cause of the acceleration of 
the heart's action. A second is the stimulation of the sym- 
pathetic nerve, possibly in the heart, but certainly in the small 
blood-vessels. The circulation in them is more rapid, blood 
passes more rapidly to and through the heart, hence directly 
stimulated to increased activity. This double mechanism is the 
first in which the action of atropine resembles that of fever. 
Other similar coincidences are the slight rise of temperature, the 
slight increase in the excretion of urea, and the diminution of 
secretions to which we have called your attention. ' 



In speaking of the anaesthetic properties of atropine, it is 
necessary to recall Botkin's experiments,- and the inference that 
this observer draws from them, namely, that atropine primarily 
paralyzes the motor nerves. These experiments were made upon 
frogs, and with overwhelmingly large doses, and the influence of 
diffusion was not taken into account. In order to exclude this 
cause of error, the vessels and nerves of the frog's leg must be 
isolated, and a ligature passed round the soft parts so tightly, 
that the poison, injected under the skin of the other limb, cannot 
diffuse through the cellular tissue, but can only reach the nerve 
by the artery. In a limb so prepared, after administration of 
atropine, the sensibility is diminished, the motility remains 
intact, while on the other leg, where diffusion has taken place, 
both are diminished equally. ^ If the ligature embrace not only 
the cellular tissue, but also the artery, no effect on the nerve will 
follow the injection of atropine. This shows that the poison 
anaesthetizes the periphery of the nerves, and not their roots or 
the nervous centres. For in this second case, as in the others, it 
has full access to these parts, but, by ligature of the artery, fails 
to reach the periphery of the nerve. No anaesthesia results, 
though this supervenes as soon as the circulation in the limb is 
restored. 

' In a part of the lecture not deemed necessary to quote. 

' Ardrio, Virchow, Bd. 24. •» Result of personal experiment. 



On Atropine 215 

The peripheric localization of the action of atropine is shown 
also by another fact. In a limb under the influence of atropine, 
an electrical current directed to the skin (or the extreme periphery 
of the sensitive nerves) causes no sensation. If the same current 
be directed to the trunk of the sciatic, evidence of pain is obtained. 
Moreover, reflex contractions occur, first in the same leg, after- 
wards in the opposite limb, showing that the conductibility of the 
centripetal fibres is intact. 

The motor nerves are only indirectly affected; that is, after 
diminution of the sensibility, there is necessarily diminution of 
reflex contractions. But at this time, direct irritation of the 
motor trunks produces as strong contractions as in a normal 
condition. 

That the spinal cord is not primitively affected seems shown 
by the following experiment : — A ligature is passed tightly around 
the body of a frog, so as to separate the anterior from the posterior 
limbs. Atropine is then injected under the skin of the anterior 
half. At first, irritation of any part of the body produces reflex 
contractions ; but as the sensibility of the nerves in the anterior 
half diminishes, irritation in this region remains without response. 
But irritation of the posterior half still produced contractions in 
the four limbs. This shows that the excited motor power of the 
cord has remained intact, for it is the only medium of communi- 
cation between the part irritated and the parts set in motion. 

Upon the voluntary muscular fibre, atropine has even less influ- 
ence than upon its motor nerves. With the unstriped muscular 
fibre however, it is different. We have seen that by stimulating 
vaso-motor nerves, atropine stimulates the contractility of the 
muscular fibre in the arteries. According to Meuriot and Orri- 
mus, in a rabbit killed after administration of a non-toxic dose of 
atropine, the movements of the intestine, always observed when 
the abdomen is opened, are exaggerated, and they infer that the 
muscular fibre is excited by the atropine. Fleming has come to a 
similar conclusion, from studying the action of atropine on worms. 
Bezold has observed, on the contrary, that the intestine of the 
rabbit remains perfectly still, but this is only after very large 
doses. 

In regard to the unstriped muscular fibre of the intestine, 
as in striped muscle, it is necessary to separate the action of 
atropine upon muscular fibre from that upon the nerves, and 



2i6 Mary Putnam Jacobi 

upon two kinds of nerves, the ganglionic and the splanchnic. In 
this connection Keuchel's experiments are very interesting.' 
Two cats were selected, similar in size, and in both the splanchnic 
nerves were cut before their junction with the solar plexus, and 
below the diaphragm. Then one of the cats was poisoned with 
0.005 of atropine. Both animals were then killed, and on open- 
ing the abdomen immediately after death, the peristaltic move- 
ments of the intestine were observed to be increased. If now, 
on the cat that had received no atropine, an electrical current 
were sent through the splanchnic nerve, this peristaltic action is 
immediately arrested, just as the heart's action is arrested by 
galvanization of the vagus. ^ But in the cat that had received 
atropine, the electrical excitation of the splanchnic produced no 
effect whatever; the movements continued. The atropine 
therefore seemed to act on the intestine by stimulating the gang- 
lionic nerves and disseminated ganglia, which provide for the 
dilatation of vessels; and by paralyzing the splanchnic nerves, 
which, by tending to contract the blood-vessels, tend to restrain 
and tonify the contractility of muscular fibre. The opposition is 
analogous to that between the pneumogastric and the sym- 
pathetic in the heart, and the action of atropine is similar in the 
two cases. 

Precise knowledge of the mode of action of atropine upon 
muscular fibre is especially important for arriving at a true theory 
of its action on rigid sphincters, where it has been so often em- 
ployed therapeutically. The usual expression, "Belladonna 
relaxes the sphincters," is extremely vague, and conveys several 
ideas more or less false, among others, that of paralysis of the 
muscular fibre. I would venture to suggest that a sphincter 
grown rigid under irritation, e. g., an os uteri during parturition, 
is, properly speaking, tetanized. It is a remarkable fact that 
tetanic contractions are always the result of a peripheric and 
consequently reflex irritation,^ as is well known clinically, and 

' Schmidt's Jahrhiicher, Bd. 143. 

' As galvanization of the splanchnic is known to contract the blood- 
vessels, and as the exaggerated movement of the intestine is known to be due 
to the rapid formation of carbonic acid, when the abdominal vessels are 
exposed to the air, it seems probable that the movements are arrested because 
the supply of blood to the muscular fibre is suddenly diminished. 

i Traumatic tetanus, of course. Strychnia tetanus seems to be of a different 
nature. 



On Atropine 217 

may be demonstrated experimentally. In a rabbit upon whom I 
had made a hemisection of the spinal cord, irritation of the limb 
on the side opposed to the section determined tetanic contractions 
in the limb on the same side. But direct irritation of the gray 
substance of the cord determined clonic convulsions in the adjoin- 
ing muscles and in the limb. 

Tetanus is not analogous to normal contractions/ but to 
cadaveric rigidity, which occurs earlier in tetanized muscles than 
others. In this state the fibre is shortened and broadened, and 
as it loses its power to contract in proportion to its shortening,^ 
really remains passive and motionless, molecular nutrition is 
arrested, and the coagulation of undecomposed myosine around 
the fibre is considered by some observers, in tetanus as in perman- 
ent death, to concur at least with change of electrical conditions in 
the preservation of immobility. The whole chain of sequences is 
broken when the initial irritation is destroyed. The anaesthesia 
of the peripheric nerves determined by belladonna allays this 
irritation, arrests the transmission of exaggerated impressions to 
the spinal cord, and hence the overwhelming motor excitation 
that had been sent from it. At the same time, by quickening the 
local circulation the atropine may facilitate the removal of coagu- 
lated or waste substances clogging up the substance of the 
muscle. 



In regard to the mechanism of the mydriasis determined by 
atropine, you will still frequently hear it ascribed to a "stimula- 
tion of the dilating, radiating fibres of the iris." Even Stellwag, 
after adducing a great many facts that speak in favor of another 
theory, concludes by ascribing to atropine a double function. 
On the one hand it paralyzes the motor ocular nerve, but on 
the other it "stimulates the nerves distributed to the muscular 
fibre in the dilator papillee, — and also in the coats of the blood- 
vessels. ' ' ^ The existence of the dilator is accepted on the author- 
ity of Koelliker, Valentin, Merkel; the distribution to it of the 

' This fact corresponds to that observed by Legros and Onimus, where 
direct irritation of certain parts of the gray substance increased the convulsive 
movements in choreic dogs. Also with the clonic convulsions of epilepsy. 

' Brown Sequard, Journal de Phys., 1859. 

3 Stellwag. Der Intraoc. Druck. Wien, 1868. P. 93. 



21 8 Mary Putnam Jacobi 

sympathetic nerve is inferred from the effects upon the pupil of 
section or irritation of that nerve. 

You know that when this section is made the pupil instantly 
contracts, and when the peripheric extremity of the severed nerve 
is galvanized, the pupil dilates again. The contraction of the 
pupil after section of the sympathetic is supposed to result from 
paralysis of these fibres, and to the exclusive predominance of the 
circular fibres controlled by the motor oculi. 

Galvanization of the cervical cord produces as much dilatation 
of the pupil as if the current were directed to the nerve itself. 
Now galvanization of the cord which is everywhere followed by 
contraction of blood-vessels, contracts the blood-vessels in the iris 
as well.^ On the other hand, paralysis of the vaso-motor 
nerves from section of the sympathetic dilatation of blood-vessels 
in the iris, as in the head where the temperature rises, is followed 
by visible enlargement of its tissue and diminution of the 
pupil. 

Stellwag insists on many facts that show a constant associ- 
ation between modification of the vascular tissue of the iris, and 
changes in the diameter of the pupil. Besides the results of 
galvanization of the cervical cord and of the sympathetic quoted 
above, he observes that mydriasis is always accompanied by a 
tumefaction of the ciliary processes, whose size diminishes during 
myasis. In the first case blood is passed out from the iris, in the 
second case, it flows back again to it. Ligature of the common 
carotid is followed immediately by contraction of the pupil, — an 
effect of the irritation of the brain from sudden anemia. But 
the secondary result on the eye is dilatation of the pupil, when the 
irritative effect has passed away, and the vascular tissue of the 
iris finds itself emptied. ' ' Did not such mighty authorities speak 
in favor of a special dilator of the pupil, we should be inclined to 
believe that the sympathetic was distributed to the walls of 
blood-vessels only, and that variations in the size of the pupil were 
due exclusively to variations in their diameter. " (Loc. cit. p. 79.) 

The suddenness with which the pupil contracts after section 
of the sympathetic shows that an effect of irritation precedes the 
paralysis of the vessels, which occurs more gradually, though 
still rapidly. This sudden contraction is due to a reflex irritation 
of the encephalon, propagated thither by the central extremity 

' Stellwag. Loc. cit. p. 76. 



On Atropine 219 

of the sympathetic. It is analogous to that which may be de- 
termined by any irritation of the brain, especially of the tu- 
bercula anadrigemina, or crura cerebelli, or by the ligature of 
the carotid. 

The contraction of the pupil is not determined by opposite 
but by different influences from that which causes its dilatation ; 
it is to be expected, therefore, that it should be expected by 
a different apparatus. In all the active physiological func- 
tions of the iris, the pupil contracts. For no purposes of vis- 
ion does it dilate actively; in obscurity, or in vision of distant 
objects, the dilatation is caused by simple relaxation of the 
muscular fibre of a sphincter, from which the normal stimulus 
had been withdrawn. It is in these cases moderate, and not to 
be compared to the widening determined by atropine, or by 
galvanization of the cervical sympathetic, an operation which 
always constricts the blood-vessels, but only occasionally affects 
the retina. Any such effect that is produced is irritative, and 
manifested by flashes of light ; hence if the contractility of the iris as 
a muscular membrane were called into play at all, it should be to 
diminish the pupil, as it does physiologically whenever the retina 
is irritated. But the reverse occurs — already a proof that the 
dilatation does not depend on the muscular elements immediately 
connected with the physiological functions of the iris, but rather 
upon its blood-vessels. 

Gruenhagen, with less respect for "weighty authorities" 
than is manifested by Stellwag, entirely denies the existence of 
muscular dilating fibres in the iris. 

" The dilating muscle has never been found, only inferred, from a supposed 
physiological necessity. . . . The only fibres that can be isolated from the 
circumference of the iris are branching fibrillae, destitute of nuclei, or covered 
with nuclei evidently belonging to epithelium, — while the fibres of the sphincter 
are easily separable, ribbon- shaped, and nucleated." . . .* 

"The arcades, described by KoelHker, are only blood-vessels, 
as may be perfectly demonstrated by preparations of injected 
specimens."^ "The radiating fibres that immediately surround 

' Zeitschrift fur Rationelle Medicin. 1866. Bd. 28, p. 180. 

^ Ibid., p. 184. Through the kindness of Dr. Knapp, I have been able 
to myself observe these vessels of the iris, with walls whose diameter is at 
least half that of their cavity. 



220 Mary Putnam Jacob! 

the sphincter, and which even Koelliker could not trace to the 
circumference, are merely dependencies of the sphincter: those 
beyond are elastic tissue.'" 

In a word, there is only one kind of contraction of the muscu- 
lar fibre of the iris, that which contracts the pupil, in obedience to 
a stimulus derived from the retina or brain, and conveyed by the 
cerebral nerve, or motor oculi. ^ Dilatation of the pupil is never 
active, but, according to its degree, depends on one of three 
different causes, ist, simple relaxation of muscular tonicity, or 
from absence of stimulus. 2d, contraction of the blood-vessels, 
from irritation of the sympathetic. 3d, paralysis of the motor 
oculi ; with complete abolition of muscular tonus, and substitution 
of the retractility of the elastic fibres. From these consider- 
ations we may more clearly understand the mechanism of the 
action of atropine on the pupil. 

Harley performed the following experiments to ascertain if 
atropine affected the sympathetic: — ^ 

In the first case the sympathetic was cut, and after the pupil 
had contracted, atropine was instilled into the eye. Thereupon 
the pupil dilated, but only partially, not so much as when the 
sympathetic remained intact. In the second case the dilatation 
of the pupil was first effected by atropine, and then the nerve was 
cut. 

The dilatation remained unchanged. 

This shows that the influence of atropine upon the sjmi- 
pathetic in the phenomenon, though real, is subordinate. 

Again, Kuyper'' found that when the pupil had been moder- 
ately dilated by atropine, excitation of the superior sympathetic 
ganglion increased the dilatation. 

This implies that the atropine acts upon another element 
in the iris than the sympathetic. The three experiments to- 
gether show clearly indeed that the atropine acts by paralyzing 
the motor oculi nerve. For the iris, while under its influence, 
cannot contract, even though submitted to the reflex irritation 
caused by section of the sympathetic. The contracting force is 

' Archiv. von Pfliiger. 1 870, p. 287. 

' The extremest contraction, as after opium poisoning, is connected 
with passive turgescence of the blood-vessels of the iris from paralysis. 
^ Edin. Med. and Surg. Journal, 1857. 
1 Quoted by B^clard, Traile de Physiol., 1866. 



On Atropine 221 

annihilated, and this force lies exclusively in the motor oculi 
On the other hand, when the sympathetic has been previously 
divided, the dilatation caused by atropine is less, for two reasons: 
1st. The motor oculi nerve is in a state of reflex irritation, and 
consequently more resistant to paralyzing influences. 2d. The 
vessels of the iris are dilated, and its tissue turgescent. 

Finally, in Kuyper's experiment, the fact that irritation of the 
sympathetic increased the dilatation already determined by 
atropine, shows that the operation and the poison have acted 
upon two different elements, so that their effects can be 
superposed. 

It is only at the beginning of atropinism, however, that the 
mydriasis is moderate, and hence resembles that which occurs 
after paralysis or section of the motor oculi. As is well known, the 
dilatation continually increases until, in extreme cases, the iris 
is reduced to a mere rim. This excessive dilatation cannot be 
ascribed to the constriction of the blood-vessels under the influ- 
ence of atropine, for although that must necessarily take place, 
in the iris as elsewhere, it is only partial, — is an initial pheno- 
menon, and its effects would be confounded with those of com- 
mencing paralysis of the motor oculi. It can only be due to such 
complete abolition of muscular tonus as must result from the 
paralysis of the muscular nerve of the iris, the motor oculi. The 
retractility of the elastic fibres then comes into play, and reduces 
the size of the iris to its minimum.' 

The action of atropine in relation to the two nervous systems 
present in the iris, cerebral, and sympathetic or spinal, is thus 
quite analogous to its action in the heart. It completely para- 
lyzes the cerebral nerve, and moderately stimulates the 
sympathetic. 

Another analogy is revealed by the researches of Keuchel on 
the submaxillary gland. It is known that irritation of the chorda 
tympani, which, as branch of the facial, represents the cerebral 
influence on the gland, increases its secretion; whereas, irritation 
of the sympathetic, by determining a contraction of the blood- 

' A familiar example of the effect of the retractility of elastic fibre upon 
inert muscular fibre may be strikingly seen in the retraction of the uterus 
of primiparae after an artificial labor, with complete absence of uterine con- 
tractions, yet followed by no hemorrhage; but, on the contrary, the formation 
of the "globe rassurant." 



222 Mary Putnam Jacobi 

vessels, diminishes the secretion.' After injection of atropine, 
irritation of the chorda tympani was without effect, and a canula 
inserted into the duct remained dry and empty. The condition 
was the same as if the chorda tympani had been paralyzed, or the 
sympathetic irritated, and there is reason to believe that both 
effects had been produced. 

In the iris, heart and submaxillary gland, therefore, the 
action of atropine is uniform — it paralyzes the peripheric ex- 
tremity of the cerebral nerves, and, by stimulating the sympathe- 
tic, determines contraction of blood-vessels and acceleration of 
the local circulation; hence a double and analogous mechanism 
by which it dilates the iris, accelerates the heart's action, and 
diminishes the secretion in the submaxillary gland. ^ 



Therapeutical Applications. 

Besides those already well known, upon which we have 
insisted careful study of the physiological action of atropine is 
continually leading to new applications in therapeutics. I have 
spoken to you of the suggestion made by Harley, in regard to the 
use of atropine as a diuretic, and as especially adapted for the 
treatment of albuminuria. I have had no opportunity to test this 
suggestion, and do not know whether it has been tried by other 
physicians than Harley. Upon another theoretical deduction 
I will however insist, as I have begun to collect some practical 
evidence in its favor. The dilatation of the cerebral blood-vessels 
that occurs as a secondary effect of atropine, ^ suggests the utility 
of this substance in functional cerebral anaemia. One case in 
which I tried atropine was that of a woman, who, three weeks 

' And which is succeeded, during the rigor mortis, by a moderate con- 
traction of the pupil. 

2 Keuchel's experiments on the splanchnic nerves above quoted, would 
seem to show an exception to the general action of atropine on the sympa- 
thetic. I do not know whether they have been confirmed; I have not yet had 
an opportunity of verifying them myself. 

i On sacrificing a rabbit forty-eight hours after administration of large, 
but not toxic doses of atropine, the pia-mater of the brain and cord were 
found engorged with blood, and the arteries of the cord dilated. The initial 
constriction of the blood-vessels in the nerve-centers, upon which, we believe, 
M. Brown-Sequard bases the employment of belladonna in epilepsy, is not in 
contradiction with this equally indubitable fact. 



On Atropine 223 

after confinement, and being then in a debilitated condition, fell 
down a flight of stairs. She remained insensible for two hours, 
and for two days was unable to walk, although she had received 
no external injury but a bruise on the shoulder. On the fifth 
day she was still so giddy that she would fall unless she supported 
herself as she walked, and suffered from continual nausea, general 
muscular weakness, and occasional blurring and blackening of 
vision — all persistent effects of the cerebral concussion. I 
ordered i-64th of a grain of atropine in solution, three times a 
day. The patient felt a sensible improvement in strength after 
each dose, as soon as its physiological effects, flushing of the face, 
increased dizziness, and a certain mental apprehensiveness, had 
passed away. On the following day, the vertigo and staggering 
had quite gone. In the second case, the diagnosis was more 
obscure. The patient presented herself at the Dispensary for 
Nervous Diseases, complaining of vertigo, general muscular 
debility, and especially paresis of the right arm, without any trem- 
bling. There was a faint blowing murmur at the apex of the 
heart. ^ Atropine was given, as an experiment, to try the effect 
upon the vertigo, i-64th of a grain, at first three times, after- 
wards twice a day. The physiological effects, as in the first case, 
were extremely well marked — the flushing of the face intense, 
and lasted an hour. Under this treatment the vertigo entirely 
disappeared, and the patient gained in strength. The treatment 
was afterwards complicated with nutritive tonics and electricity. 
In a third case of cerebral and general anaemia, without any sign 
of local cerebral lesion, but with vertigo and floating specks 
before the eyes, the vertigo quite disappeared under the exclusive 
use of belladonna extract. The other anaemic symptoms were 
only relieved by blood tonics. 



Finally, there remains for us to say a few words on the so- 
called antagonism existing between belladonna and opium, in 
cases of poisoning. Let us notice, in the first place, that the real 
antagonism conceivable is not that between opium and bella- 
donna, but between some of the effects produced by the one in the 
living organism, and those determined by the other. Now, there 

' About six months afterwards this patient developed marked symptoms 
of paralysis agitans. 



224 Mary Putnam Jacobi 

are no two substances whose entire series of physiological effects 
are directly opposed to each other. There are no true antidotes 
to poisons but such agents as effect a chemical alteration of the 
toxic substance, and opium and belladonna have no such mutual 
reaction. Moreover, it is certain that the physiological effects of 
the two drugs are not in all points contrasted. Mitchell,* 
Eulenberg, ^ and Harley^ have shown, both in experiments upon 
animals and in observations upon man, that opium and bella- 
donna, taken in succession, caused greater acceleration of the 
pulse than the belladonna alone; also that when sleep has been 
induced by a therapeutic dose of morphine, atropine will not 
disturb, but rather render it more profound. (Harley.) The 
anaesthesia, diminution of secretions, dysuria, produced by one of 
these substances, are determined by the other also, and cannot 
therefore be antagonized. But, on the other hand, the pupils 
contracted by morphine were seen to widen by atropine, or the 
reverse, and the respiration, slackened by morphine, to be slightly 
accelerated by atropine. (Erlenmeyer.) Again, though mor- 
phine prove unable to slacken a pulse accelerated by atropine, the 
fact that atropine accelerates a pulse that has been slackened 
by morphine is of the highest importance in toxicology. This 
may be seen even in the rabbit, although this animal is much more 
susceptible to morphine than to atropine. In a rabbit to whom I 
had given hypodermically three grains of morphine in the course 
of an hour, the pulse was 148, respiration twenty-four, pupils 
moderately contracted, animal in partial stupor, but not insensi- 
ble. Three-quarters grain of atropine were injected, and in ten 
minutes the pulse had risen to 240, the respiration to thirty-two, 
though the pupils were not yet dilated. After injection of a grain 
and a half more, the ears became very hot, with marked dilatation 
of the arteries. This subsided again after the injection of one- 
half grain of morphine. On further injection, in divided doses of 
five grains of morphine, the pulse became very weak, but num- 
bered about 200. Injections of five grs. atropine then restored 
dilatation of auricular arteries, and caused full dilatation of the 
pupils, one and three-quarter hours from the time of its first 
administration. The animal recovered completely. The effects 
upon the rabbit's ears were particularly noteworthy in this case. 

' Am. Journal Med. Scienca, 1865. 

* Bulletin de Therap., 1867. J Old Vegetable Narcotics. 



On Atropine 225 

It corresponds to that observed on the ears of guinea-pigs by 
Wegner,' and to the well-known experiments of Wharton Jones 
on the frog's foot with solution of atropine and Battley's solution 
of opium. The attempt to prove or disprove an "antagonism" 
between opiimi and belladonna frequently confuses the percep- 
tion of the real questions, viz.: What physiological effects of 
belladonna are theoretically useful in the morbid state induced 
by opium? and further, to what extent do recorded cases of 
poisoning show that these effects have been produced? How 
have others been modified? Finally, what explanation can be 
given of the toleration shown by many patients for one poison, 
while they are already under the influence of the other? 

This statement of the case is so simple as to almost seem 
superfluous, were it not evidently so often overlooked. In the 
experiments of Camus, so often quoted, full toxic doses of mor- 
phine and atropine were given almost simultaneously, and before 
the effects of morphine had had time to become manifest ; in other 
words, before the conditions of resistance to the one poison had 
been developed by the other. It was to be expected, therefore, 
that the animal should feel the full force of both, and succimib. 

For the morphine and atropine, even when acting upon the 
same organ, and in an opposite manner, affect different parts of 
its apparatus. Thus, atropine accelerates the pulse by paralyz- 
ing the peripheric extremity of the pneumogastric; morphine 
slackens the pulse by increasing cerebral pressure and the tonus of 
the central end of the pneumogastric. It is therefore easy to 
understand why atropine should accelerate the pulse in spite of 
morphine, while morphine should be unable to reduce an atropine 
acceleration. When the cardiac end of the pneumogastric is 
paralyzed, it avails little that the tonicity of the central end be 
increased. And when this has been increased by the opiimi con- 
gestion of the encephalon, the effect on the pulse is nullified so 
soon as the connection between the heart and brain is severed by 
paralysis of the pneumogastric. Again, the contraction of the 
pupil, which occurs after irritation of nearly all the organs of the 
encephalon, is also determined by the cerebral congestion of 
opium. While, to produce dilatation, the atropine acts on the 
periphery, on the iris itself, paralyzing the motor oculi nerve, and 
so cutting it off from the brain, and moreover contracting its 

' Quoted by Stellwag. Der. Intraoc. Druck. P. 6i. Wien, 1868. 



226 Mary Putnam Jacobi 

blood-vessels by stimulus of the sympathetic. It is evident that 
both these effects on the iris might be produced, although no 
change had taken place in the condition of the brain, and hence 
dilatation of the pupil may occur after administration of atropine 
in opium poisoning, yet the patient remain narcotized, and finally 
succumb. Thus, in Blake's case,^ the child, who had swallowed 
a teaspoonful of laudanum during convalescence from pneumonia, 
was treated with eighteen drops of fluid extract of belladonna 
in divided doses. The pupils began to dilate after the second 
hour, but other symptoms were aggravated, and the patient died 
in thirteen hours. Here the effect of the opium was much intensi- 
fied by the pulmonary disease, and the dose of belladonna was 
small. In one of Norris' cases at the Pennsylvania Hospital, a 
man of 55 years, who had taken an ounce of laudanum, was 
treated nine hours afterwards with eight and a half grains of ext. 
bellad. in divided doses during three hours. At the end of this 
time the pupils dilated, but the general condition remained the 
same, the pulse almost insensible, and the patient died three hours 
later. 

Again, there are cases where the dilatation of the pupils 
did not occur until after enormous doses of atropine have been 
taken, had manifested their influence in other ways, especially 
by the acceleration of the pulse, and been followed by a commence- 
ment of convalescence. Here the paralytic turgescence of the 
blood-vessels of the iris persisted after other symptoms. Thus, 
in one of Blondeau's cases, ^ a teaspoonful of laudanum had been 
swallowed, and occasioned drowsiness, coldness of extremities, 
contracted pupils, but no coma. A fluid drachm of tincture of 
belladonna was given in divided doses, and the pulse and temper- 
ature rose under its influence, but the pupils remained very con- 
tracted until some time after convalescence had evidently set in. 

In Duncan's case,^ two ounces of laudanum had been taken, 
and the patient was in a profound coma when the belladonna 
was given. This persisted after administration of an ounce 
of tinct. belladonna in divided doses, and the pupils continued to 
contract more and more. Then fifteen grains of extract bellad. 
were given by the rectum, and two hours afterwards the pulse 
rose, and the respiration became freer. Then two grains more 

' Archives Gen., 1864. Quoted from Pacific Journal. 

^ Ibid., 1865. i Archives Gen., 1864. Am. Med. Journ., 1862. 



On Atropine 227 

of the extract were given, and thereupon symptoms of bella- 
donna intoxication occurred, with, for the first time, dilatation of 
the pupils. Thus the turning-point in the narcotism, as mani- 
fested by the effect on the pulse and respiration, was reached 
before the pupils were moved, but the return of consciousness was 
delayed until the moment of their dilatation. 

In the remarkable case related by Constantin Paul,^ where 
the injection of an ounce of laudanum had thrown the patient 
into a state of intense excitement instead of coma, but accom- 
panied by great contraction of the pupil, a large part of the laud- 
anum had been rejected by vomiting before any belladonna was 
given, and the recovery would probably have taken place with- 
out any medication. But the immediate effects of the bella- 
donna upon the symptoms were none the less striking. Twelve 
drops of tinct. bellad. were given every hour, and in ten minutes 
after each dose there was marked amelioration of the vertigo 
and violent nausea, though the pupils remained contracted. 
The opium symptoms returned in from one-half to three-quarters 
of an hour, to disappear again with a fresh dose of belladonna. 

By narrowing the interval between the doses, the convales- 
cence was definitely established; but not until the patient had 
taken over f . 5 ij of the tincture did pallor of the face and dryness 
of the mouth appear, while the pupils only dilated after ingestion 
of nearly f 5 iv. The effect of opium upon the dilatation of the 
pupils, in cases of belladonna poisoning, is more difficult to 
appreciate because it is omitted from many of the histories. In 
Lee's, ^ however, where a child of 6 years old, poisoned with bella- 
donna, was treated with I20 drops of laudanum, it is said that the 
purple flush began to fade from the face "as the pupils con- 
tracted." In a case recorded in the Dublin Medical Press for 
1864, the pupils, dilated and motionless after | grain of atropine, 
began to contract under the administration of opium that had 
been preceded by an emetic ; at the same time the eruption began 
to fade. After 4 grains of opium had been taken the pupils were 
normal, and the patient (who was only 2| years old) fell quietly 
asleep. 

But on the other hand, in a case quoted in the Union Medicale, 
1863, where from IQ-15 drops of laudanum were given to a child 
26 months old, poisoned by an unknown quantity of belladonna, 

^Bulletin de Therapeutique, 1867. ' Am. Journ. Med. Set., 1862. 



228 Mary Putnam Jacobi 

the pupils did not contract until some time after the patient had 
fallen asleep, and convulsive movements had ceased. The age 
of the patient in this case renders this fact all the more remark- 
able. 

Hence observation of facts justifies the expectation of theory, 
that in cases of poisoning by one of the two substances, opium or 
belladonna, the therapeutic influence of the other cannot be tested 
by the state of the pupils, although it is in their movements that 
the physiological opposition of opium and belladonna is most 
manifest. The pulse affords a much better test. In all cases of 
laudanum poisoning with a slow pulse that have recovered 
under the administration of belladonna, the pulse has risen in 
frequency and strength, and we have already pointed out several 
cases where this rise marked the entrance upon convalescence, 
and preceded, by a considerable interval, the dilatation of the 
pupil. In an observation in the Bulletin de Therapeutique, 1865, 
the patient had taken 5 drachms of laudanum, and the bella- 
donna was not given until 24 hours afterwards. At this time the 
effects of the poison were already attenuated, but there remained 
frequent vomiting, the pupils were contracted and the pulse 52. 
After hypodermic injection of 10 drops of a solution of atropine at 
I per cent., the vomiting instantly ceased, and the pulse rose to 68. 

In another case in the Lancet, 1869, the patient was comatose, 
with stertorous breathing. The pulse was not counted until 
after the administration of | grain of atropine, but it was then 
found at 160, and at the same instant the pupils dilated widely. 

In one of Blondeau's cases, ' 5 ijss of laudanum had thrown the 
patient into stupor, but not coma, and the extremities were cold, 
the pulse small, slow, and intermitting. After the administration 
of f. 5 j of tinct. belladonna, in doses of 10 and 5 drops the pulse 
rose, the extremities became warm, and convalescence progressed 
from this moment.^ 

In Anderson's case, Edin. Monthly, 1854, profound coma had 
set in, after ingestion of 9 grains of morphine, taken for delirium 

^ Gaz. Hebd., 1865. This case already mentioned, in speaking of the 
dilatation of the pupil. 

^ This case is rejected by Harley, because the dose of laudanum was 
not excessive, and patient might have recovered spontaneously. Never- 
theless it does show perfectly the mode of action of belladonna upon opiate 
symptoms, when these are not too intense to be modified. 



On Atropine 229 

tremens during a period of 36 hours. The pulse was slow and 
very feeble. 8 drachms of tincture of belladonna were given in 
divided doses, f . 5 j every half hour, and then the pulse rose, and 
became strong. At the same time the coma was quite dissipated. 
In this case the pupils dilated after the 3d dose, before any really 
favorable symptom was manifest, but the pulse, respiration, and 
consciousness were only affected at the ninth hour. 

In Blondeau's second case {Archives de Medecine, 1865) 100 
drops of tinct. belladonna were given in the course of an hour and 
a half, the patient remaining insensible, and the pupils contracted 
and motionless. After the last ten drops the pulse increased in 
force and frequency, (the pupils began to dilate at the same time) . 
The recovery was assisted by frictions ( ?) of the thorax. 

In McGee's case (Am. J. Med. Sc, 1872) the coma, deter- 
mined by 30 grains of opium, was combated by subcutaneous 
injections of one-fourth of a grain of sulph. atropia, in divided 
doses. The pulse rose to 140, and at the same time the pupils 
dilated and vomiting occurred, which emetics had previously 
failed to produce. There was afterwards some return of the 
opium sjTuptoms, somnolence and contracted pupils, but these 
disappeared spontaneously, so that the recovery really dated 
from the rise of the pulse. 

There is only one case on record where the rise of the pulse 
failed to initiate recovery. This is the remarkable case of Norris, 
at the Pennsylvania Hospital, where 75 grains of morphine had 
been swallowed, and marked somnolence had not occurred until 
four hours afterwards. Before this time the patient was treated 
with tannic acid, an emetic of sulph. zinc and ipecacuanha, a 
strong decoction of coffee, and 20 grains of extract of belladonna. 
As the coma advanced, 20 grains more of extract belladonna were 
given in two doses, the pupils dilated, the pulse rose from 80 to 
120, but the somnolence persisted. The patient ultimately 
recovered under the free use of stimulants. This case much 
resembles that of Camus's rabbits, for the doses of morphine 
and belladonna were enormous, and administered nearly simul- 
taneously, the first 20 grains of the extract having been given 
before the effects of the morphine were well developed. As in 
the experiments, therefore, the effects of the two poisons, instead 
of neutralizing each other, accumulated, and a belladonna coma 
succeeded to that induced by morphine. 



230 Mary Putnam Jacobi 

In Norris's other case, already quoted, with a fatal issue, 
auscultation of the heart showed 120 pulsations, but these were 
so feeble that the pulse at the wrist was almost imperceptible. 
The atropine failed, therefore, to act as a cardiac stimulant. 

In opium poisoning the great danger lies in the congestion of 
the brain. The contraction of the pupils, the coma, the slowness 
of pulse and respiration are of importance, as symptoms of this 
congestion, and the latter more especially, as initiating the 
mechanism of death. Any antagonist to opiiun that does not 
act as a chemical antidote in the stomach, must act by dissipating 
the cerebral congestion. Hence it is not easy to understand 
why Harley pronounces atropine useless because "it does not 
influence the respiration, where the action of opium is the most 
dangerous." The surest way to restore the respiration is to dissi- 
pate the cerebral congestion. And this may be done, when the 
paralysis is not too complete, by all agents that quicken the 
heart's action, and more especially accelerate the circulation 
in the brain. Now Harley himself admits that atropine ' ' is one 
of the most powerful cardiac stimulants we possess," — he points 
out the immediate relief to the nausea occasioned by therapeuti- 
cal doses of morphine, from its depressant action on the vagus, 
that is afforded by small doses of atropine, which neutralize this 
action. It is not therefore true that the cerebral effects of mor- 
phine and atropine are not opposed to each other, and Harley's 
experiments, showing that the sleep induced by morphine is not 
disturbed, but rendered more profound by atropine, does not dis- 
prove their antagonism. 

In the cases on record, the belladonna has been used when the 
patient was in one of two conditions: 1st, a state of restlessness 
and intense nausea; 2d, somnolence or complete coma. In the 
first case, the relief has always been immediate and striking. 
Thus in the first case of Behier,^ the patient had been partially 
relieved by abundant spontaneous vomiting, but remained 
alternating between somnolence and extremely painful nausea 
and giddiness. One-fifth of a grain of ext. bellad. was given, 
and immediately these symptoms disappeared. In the case 
already referred to, recorded in the Bulletin de Therap., 1865, 
the effects of the laudanimi, ingested about eighteen hours pre- 
viously, were passing away, but the pulse was at 56, and there 

» Archives de Medicine, 1864. 



On Atropine 231 

was frequent vomiting instantly checked by tlu' injeHtion of a 
very minute quantity of atropine. [Sec above.) 

The same efTect is seen in the case of Constantin Paul's, al- 
ready quoted, where violent nausea and agitation constituted the 
main symptoms of the o])ium jjoisoninj;, and were strikinj-jy 
relieved by belladonna. As has been said, a marked amelioration 
occurred ten minutes after each dose of twelve drops of the 
tincture, — and this amelioration was ])('rmanent so soon as the 
interval between the doses was shortened from one hour to three- 
quarters, which was done after the sixth dose. It is not there- 
fore correct to say, as Ilarley does in his comments on this case, 
that although the belladonna was given from the second hour 
after the poisoning, no decided effect was produced till the fifteenth 
hour. It was remarkable in this case, where the opium had 
produced agitation and not somnolence, the first phenomenon of 
definite recovery was sleep. 

In the second class of cases, where the patient was comatose 
at the time of commencing the belladonna treatmci)!,, the effect 
of this latter is precisely measured by its effecl, on I he pulse. 
If the pulse rises, the coma b(;gins to be dissipated, and if the 
coma returns, the pulse has fallen again. That the effects of 
atropine, like those of other stimulants, should sometimes be only 
temporary, and unable to overcome the opium conge;;tion, proves 
no more against the usefulness of atropine than against that of 
coffee or brandy. That, when the two poisons have been admin- 
istered simultaneously or in rapid succession, the more en(;rgetic 
effect of atropine on the pulse may be manifested without any 
corresponding modification of the cerebral symptoms merely, 
show that until the conditions f^f resistance have bec*n developcrl 
by the action of one poison, the system is equally open to the 
effects of both; but that, in many casf;s (A opium coma, bella- 
donna has quickened the heart's action, and by so doing hel[K;fl 
to dissipate the cereVjral congestion; that, in a cert.'u'n number of 
cases, this effect has been permanent, and even to be attributed to 
the belladonna alone, we think unquestionable. 

Most of the recorded cases have been tal/ulated by Ilarley, 
and commented upon. It is v/orth while to pa;;:-; briefly in review 
both the cases and the comments. 

In the first three ca^x;s noticed, that of Norris,' iilake,' 

'American Journal, 1862. ' Boilon Med. and Surg. Journal, 1864. 



232 Mary Putnam Jacobi 

and one from the Pacific Journal, 1862, the administration of 
belladonna was unsuccessful. We have already noticed these 
cases, and pointed out that in none was the pulse perceptible at 
the wrist. ' 

Concerning the case of Anderson, already quoted, Harley 
remarks that the coma persisted from 10 to 14 hours after the use 
of belladonna. But we have seen that it was dissipated as soon as 
the pulse rose. 

In Motherwell's case,"" f. § jss of laudanum had been taken 
and twelve hours later the patient was completely comatose. 
The belladonna treatment was begun the 14th hour, and the 
coma did not begin to pass away before the 17th. But this 
was as soon as could be expected, and the amelioration coincided 
with dilatation of the pupils. [Nothing is said about the pulse.] 

Now when, as in some cases considered above, the coma has 
been really aggravated by belladonna, the pupils dilate, without 
other sign of amelioration. 

In Mussey's case,^ there was coma and a pulse of 50, the fifth 
hour after ingestion of f. 3 j- of laudanum, which persisted in spite 
of vomiting induced by strong coffee at 3d hour. At 5th hour, 
grs. vj of ext. bellad. were taken; at 6th hour, f 5i tinct. bellad. 
and at 7th hour, coincidently with dilatation of the pupils, the 
pulse and temperature improved. By the 8th hour the skin was 
warm, pulse 100, and stupor had disappeared. 

Harley overlooks these signs of improvement at the 7th and 
8th hours, and insists on the fact that consciousness did not 
return till the nth hour, 6 hours after administration of bella- 
donna. According to him the coma was prolonged by the bella- 
donna. But although the patient remained unconscious after 
some of the characteristic effects of belladonna were produced, 
the sleep lost its stupor and alarming character in two hours after 
the administration of the belladonna. 

In Lee's case,'' where a child of two years old was in a pro- 
found coma from laudanum, tinct. bellad., given in doses of 15 
minims, produced a most decided effect. After the second dose 
the temperature of the skin rose ; after the third the pupils became 

' See above in regard to the cardiac pulsations. 

* Med. Times and Gaz., 1862. 

^ ATner. Journ., 1862; also Cincinnati Medical. 

* Am. Journ. Med. Sc, 1862. 



On Atropine 233 

sensible to light, and the child spoke; after the fourth, the pupils 
suddenly dilated, the face, neck, and arms became scarlet, and 
the child began to laugh and cry in the first stage of atropine 
poisoning. Recovery was prompt. Concerning this case Har- 
ley sa^'s that the necessary details are omitted, because the 
quantity of laudanum was not stated. But it is unnecessary to 
know the exact quantity of the poison when the condition of the 
patient is accurately stated, — since in different individuals, and 
different conditions of absorption, the dose required to produce 
any given effect is very variable. 

In Mitchell's case (iV. Y. Med. Journal, vol. iv.), ingestion of 
grs. V. of sulph. morphine had not produced coma 4I hours after- 
wards. The patient still answered questions correctly. It was at 
this time that f. 5 vj tinct. belladonna were given, and as in 
Norris's case, already discussed, the stupor continued to increase 
till the loth hour. During this time f . § v of the tincture were 
given in two doses, and ^d gr. atropine in four doses. The first 
characteristic effect of belladonna appeared at the loth hour after 
the first dose of atropine, when the pupils began to enlarge, and 
after the last dose there was a scarlet flush from head to foot, with 
dryness of the tongue, and soon the stupor was replaced by busy 
delirium. 

This case is more interesting pathologically than therapeuti- 
cally, for the amount of belladonna taken was relatively more 
poisonous than the five grains of morphine: and galvanism was 
administered between the sixth and tenth hours. The continual 
increase of the coma, during the administration of doses of bella- 
donna themselves large enough to produce paralysis and coma, 
might be attributed to the cumulative effect of the two poisons, 
were it not for the absence of mydriasis. This always occurs in 
belladonna coma, and we have seen that it may occur when the 
system is saturated with belladonna, even though the narcotism 
first determined by opium persists. The pulse was already para- 
lyzed and 170, before the atropine was given, so that no char- 
acteristic effect on it could be produced. It descended, probably 
under the influence of galvanism, to 150 and 140, As the 
atropine only dissipates the coma by quickening the pulse, it 
could not be expected therefore to have any direct effect upon the 
narcotism in this case. This case, and the analogous one of 
Norris (poisoning with seventy-five grains of morphine, stupor 



234 Mary Putnam Jacobi 

not till four hours afterwards) can only be explained by an arrest 
of absorption. It is on account of such arrest, from paralysis 
of the nervous, muscular, and secretive apparatus of the stomach, 
that spontaneous recovery has occurred after enormous doses of 
opium. Camus has collected a few such cases in his thesis.' 
The belladonna is absorbed as gradually as the opium had been, 
and being eliminated rapidly by the kidneys, does not accumu- 
late in sufficient quantity to produce its own paralytic effects. 
Hence two facts, observable in Mitchell's case: ist. That the 
first visible effects of doses large enough to produce a coma, were 
those that belong not to the latter, but to the initial period of 
intoxication, namely, a scarlet flush and busy delirium. 2d. 
That a large amount of urine was passed before recovery was 
complete. It seems probable, and the hypothesis would be 
easily tested by direct experiment, that the diuresis determined 
by the belladonna helped to eliminate the morphine from the 
system. The experiments of Percy show that one-quarter grain 
of atropine would apparently neutralize the effects of a toxic dose 
of morphine, when plenty of water was allowed to the animal, 
and free diuresis occurred; but that death would follow when, 
all other circumstances remaining the same, the supply of water 
was cut off. Hence a second, though subordinate mode of action 
in which atropine may be useful in opium poisoning. In cases 
where its influence as a cardiac stimulant cannot be exerted, or is 
unavailing, it may still act as a diuretic, and favor the elimination 
of morphine from the system. In Lucas' case, ^ where a child of 
eleven had swallowed f. 5 jss. of laudanum, and, three hours 
afterwards, was almost completely comatose, Harley lays great 
stress on the fact that in the treatment electro-magnetism was 
employed as well as belladonna. But this was only given in 
order to arouse the patient sufficiently to swallow the bella- 
donna, and the effect of each application was most transitory. 
The treatment was commenced at the eighth hour, with one grain 
ext. belladonnas, and this repeated six times in the course of three 
hours. After the fourth dose the stertor was less marked, pupils 
less contracted, and pulse 104. After the sixth dose the stertor 
quite disappeared, the face was highly flushed, the pulse at 136. 
The effect of the belladonna in this case seems indubitable. 
Here, f. 5 jss. of laudanum, or forty-eight times the full medicinal 
' Theses de Paris, 1865. ' Med. Times and Gaz., 1865. 



On Atropine 235 

dose, produced coma with cold extremities and livid face in three 
hours, showing that absorption had fully taken place. Whereas 
in Mitchell's observations, just discussed, after grs. v. of mor- 
phine or only thirty times medicinal dose, we have been obliged 
to infer that the stomach was paralyzed by the excess, and 
hence absorption deferred. It is certainly difficult to explain 
this variable action, but the fact is incontestable, — for the patient 
was still able to respond to questions at four and one-half hours 
after the ingestion of morphine. In the absence of experiments 
that might easily measure the rate of absorption, hypothesis is 
useless, and mere guessing. It cannot be said that laudanum is 
always absorbed more quickly than morphine, for some of the 
most striking cases of delay in toxic symptoms have been ob- 
served after enormous doses of laudanum. 

In Duncan's case, ^ Harley again attributes the prolongation 
of the coma to the enormous doses of belladonna (f.5 j tincture, 
and grs. xvij extract) that were given; f. 5ij of laudaniun had 
been swallowed, and in one and one-half hours, patient was already 
almost insensible to external impressions, and sunk in a comatose 
sleep. After the administration of the f. 5 j of tincture in a single 
dose (preceded by emesis), the coma persisted, and the pupils 
continued to contract, the skin grew cold and covered with a 
viscid sweat, the pulse imperceptible. Since the pupils re- 
mained contracted, it is difficult to attribute this coma to the 
action of the belladonna. When the pulse is accelerated without 
improvement of other symptoms, it may sometimes be questioned 
whether the diffusion of the opium is not thereby favored, and its 
toxic effects increased. But in this case no effect was produced on 
the pulse. Moreover, if f. 5 j of tincture had added to the opium 
paralysis, the additional administration of fifteen grains of extract 
should have been fatal; yet after this the pulse rose, and the 
respiration at the same time became freer. Two grains more 
were given, and an hour later the pupils dilated, regained their 
sensibility, the patient was roused from the coma, and replied to 
questions. 

In Adamson's case^ of poisoning by laudanum, f. 5iij tinct. 
belladonna given in divided doses between 3f and 9 hours after- 
wards. From the 26. to 5th hour there was no improvement, but 
at the 7th hour the patient was sufficiently roused to answer 

' Am. J own. Med. Sci., 1862. ^ British Medical Journal, 1866. 



236 Mary Putnam Jacobi 

questions. Harley objects to this case that other means were 
used besides the belladonna; but these consisted exclusively of 
an emetic of sulph. zinc at about the 2d hour, which induced no 
vomiting; and in the removal of a little fluid by the stomach- 
pump. 

In Cazin's case, quoted in the Edin. Monthly, 1855, f. 5v. 
laudanum had been taken in two doses. 4f hours afterwards the 
patient could not be roused from stupor and the pupils were 
contracted to mere points. Tinct. belladonna f . 5 J and f . 5 i j 
were given between 5! and 5f hours, and at 7th hour the pulse was 
stronger, the pupils began to dilate, and the stupor to lessen. 
The improvement continued steadily to the loth hour, which 
marked definite recovery. 

Harley again objects that in this case electricity and emetics 
were also used, and that their effects complicate those of bella- 
donna. But these means were tried about the 4th hour, and an 
hour afterwards, when the first dose of belladonna was given, the 
patient was profoundly comatose, as above described. But 
improvement began about an hour after last dose of belladonna. 

To resume the conclusions that may be drawn from the above 
analysis of observations and experiments : — 

I St. If very large doses of belladonna be given before the 
establishment of opium coma, still more, if given simultaneously 
with the opium, the paralytic ^effect of both poisons may be 
produced. [See experiments of Camus, which I have repeated 
with similar results — case of Norris, case of Mitchell.] 

2d. When belladonna is given alone, in doses sufficient to 
produce coma, the pupils dilate, and the pulse is accelerated, 
until after the most advanced stage, when it falls. When, there- 
fore, a coma persists in a patient who has taken both opium and 
belladonna, if there is dilatation of the pupils and rise of the 
pulse, the coma may be attributed to the accumulated effect of 
both poisons. But when the pulse and respiration remain slow 
and the pupils contracted, there is no proof that the belladonna 
has exerted any influence at all, and the coma must be ascribed 
exclusively to the effect of opium not yet counteracted by 
medication. 

3d. It is known that after excessive doses of opium, symp- 
toms of poisoning are often delayed longer than when smaller 
quantities have been taken, and the delay is attributed to tem- 



On Atropine 237 

porary paralysis of absorption. This same condition partly 
explains the impunity with which patients plunged in opium 
coma bear such enormous doses of belladonna. If only small 
quantities are absorbed of the mass contained in the stomach, 
while elimination is rapidly going on by the kidneys, some time 
might elapse before any great amount is circulating at once in the 
blood. 

4th. The diuresis determined by atropine favors the elimin- 
ation of the opium alkaloids, and in some cases recovery seems to 
be mainly due to this cause. 

5th. The main action is however upon the circulation. The 
capillaries, paralyzed and distended by opium, are directly 
stimulated to contract by belladonna, and at the same time 
the heart is quickened by being released from pressure of the pneu- 
mogastric. A double influence is therefore exerted to dissipate 
congestions; and as cerebral congestion lessens, the respiration, 
so dangerously menaced, becomes freer. 

6th. Hence the therapeutic value of belladonna in any given 
case must be calculated exclusively from its effect on the pulse 
and on the kidneys. The dilatation of the pupils only shows that 
the system is under the influence of atropine, not that that in- 
fluence is beneficial. Coma may persist, and the patient die, 
with dilated pupils. This is the case when animals are poisoned 
by toxic doses of opium and belladonna given simultaneously. 

7th. In therapeutic doses, the pulse, slackened by morphine, 
is always accelerated by atropine, and the reverse is not true. 
The effect of atropine on the pulse is relatively more energetic, 
for reasons above detailed. But it is certain that in the majority 
of toxic cases recorded, the acceleration of the pulse is only pro- 
duced with difficulty, and then coincides with an amelioration of 
the narcotic symptoms. In the one or two instances where there 
was not such amelioration [case of Norris], the pulse, though ac- 
celerated, remained very feeble, so that no real stimulation of the 
circulation was produced, but only a double paralysis. There are 
cases where immense doses of belladonna have been swallowed 
at the very moment that absorption was beginning to take place, 
after the temporary stupor induced by opium, and before the 
establishment of coma had again diminished its activity. 

8th. There is nothing either in theory, or in the observation 
of facts to necessitate or justify the enormous doses of belladonna 



238 Mary Putnam Jacobi 

that have been given. It is known that the acceleration of the pulse 
and rise of vascular tension are produced by small doses, and the 
contrary effect by large. It is more rational to administer 
lUxv of the tincture at intervals of a quarter or half an hour, 
and this treatment has been followed by more satisfactory results 
than the administration of f . 5 j at a dose. It is absurd to calcu- 
late the amount of belladonna needed from the amount of opium 
that has been swallowed, for the neutralization required is not 
chemical, but physiological, and to be adapted to the reactions of 
the organism. 

9th. The toleration of such enormous doses of an opposite 
poison is none the less a remarkable phenomenon in the pathology 
of opium poisoning. When taken simultaneously, the effects are 
different from those noticed when the belladonna was given some 
time after the opium, though before the occurrence of coma. 
These effects are of three kinds, ist. No toxic sjrmptoms may be 
observed. [Case of Cazin, ' where a liniment containing f . 5 jss. 
of laudanum, and f. B ss. tincture of belladonna was swallowed, 
without other result than somnolence and dilatation of pupils.] 

In this case the dose of belladonna was not excessive, there was 
abundant diuresis [the patient had previously had complete 
retention of urine], and this easily explains the elimination of 
morphine before any narcotism could be produced. 

2d. There may be severe symptoms of poisoning, but followed 
by spontaneous recovery. [Case of Christison, — three successive 
injections containing each 3ij of opium, and 5 ss of belladonna 
leaves.] In this case there was profound coma in three hours, 
with dilated pupils, showing predominance of the belladonna 
poisoning. 

3d. Coma may set in, apparently less profound than results 
from opium alone, but tending to a much more rapidly fatal issue. 
This has only been seen in experiments on animals, for in the three 
cases where death has followed the belladonna treatment, the 
doses of belladonna were much smaller than in those that re- 
covered. (Grs. vj of extract, in Norris's case, f. 5 ij tincture, 
in Blake's and only lU xviij in the case of the child related in the 
Pacific Journal.) 

Even therefore when several hours have elapsed after the 
administration of belladonna, without occurrence of any per- 

' Traite de Plantes Medicinales. 



On Atropine 239 

ceptible amelioration, and where the therapeutic efficacy of the 
drug might apparently be called in question, the problem of its 
tolerance remains to be explained. We have suggested a partial 
explanation in the condition of its absorption and elimination; 
we do not affirm that none other is possible nor needed. But the 
combination of properties possessed by atropine as a diuretic, a 
cardiac stimulant, and stimulator of the vaso-motor nerves, 
affords a theoretical explanation of its action that at least lies 
nearer to facts positively known than the hypothesis of vague 
"resistance." When a certain amount of morphine had been 
eliminated from the system by the kidneys, the atropine is then 
able to exercise its most important action on the circulation, and 
thus directly dissipate the cerebral congestion. 

It is extremely important to settle this question by examin- 
ation of the urine of patients comatose from opium, and to whom 
atropine or belladonna has been given. ^ 

loth. Belladonna is no "antidote" to opium, nor even to the 
entire series of pathological phenomena determined by that 
poison. Nor is this surprising, since there are no antidotes to 
pathological entities which do not indeed exist. But theoreti- 
cally and practically it does modify some of the phenomena of 
opium poisoning, and may be used to advantage within the limits 
of the following rules. 

1st. It should not be given as a prophylactic, but only to 
combat conditions already existing, either of restlessness, nausea 
and vomiting, or of somnolence, stupor or coma. 

2d. It should not be given in large doses, but in small ones 
[m xv] frequently repeated. 

3d. It is safe to continue the administration so long as the 
pupils are not dilated nor the pulse accelerated. If dilatation has 
taken place, yet the iris remains motionless, — if the pulse has 
become rapid and weak, and coma still continues unabated, — 
further use of atropine would only increase the mischief. 

4th. The use of adjuvants, as emetics, coffee, if necessary, 
electricity, is to be recommended as much in the belladonna treat- 
ment as in any other. The previson of the physiological effects to 
be expected from belladonna enable us generally to analyze its 
influence, even when a complex medication has been employed. 

' This elimination in substance of atropine with the urine is known to be 
the cause of the dysuria that so frequently attends therapeutical doses. 



PATHOGENY OF INFANTILE PARALYSIS/ 

(Paper read before the New York County Medical Society, 
December 22, 1873.) 

There is probably no other affection than infantile paralysis 
which offers so remarkable a contrast between the frequency of 
its occurrence and general agreement in regard to the description 
of its symptoms, and the extreme rarity of opportunities that 
have been offered for its anatomical investigation. Brunniche^ 
observed seven cases in one year in a general clinic; and in the 
same length of time I have myself observed thirteen cases of 
paralysis in children, of which nine were true infantile paralysis. 
West^ gives a table of thirty-two cases; Hillier,'' of twenty-four. 
Duchenne fils^ tabulates observations of seventy cases. The 
books of Dr. Knight's hospital, of this city, contain, in the space 
of two years, records of one hundred cases of paralysis, of which 
nearly two-thirds belong to the special affection that occupies 
us. Volkmann,^ who gives no table, says that he has seen 
over one hundred cases; and BarwelP makes an analogous 
assertion. 

Nevertheless, the number of autopsies recorded since Under- 
wood first described the disease, in 1789, is not more than twenty- 

' Reprinted from The American Journal oj Obstetrics and Diseases of Women 
and Children, 1874. 

' Journal ftir Kitidefkrankheiten, Bd. 36, 1861. 

3 Childien's Diseases, i860. 

" Diseases of Children, 1868. 

s Archives Gen., 1864. 

<> Sammlung klinischer Vorrdge, No. I, 1870. 

1 Lancet, 1872. 

340 



Pathogeny of Infantile Paralysis 241 

.seven, if limited to children, or twenty-nine, if we include two 
cases of quite analogous disease observed in the adult. Even 
these few autopsies are not all known to even recent writers on 
the subject. In i860, Heine,' in his second edition, knew of but 
three — those by Hutin, Longet, and Fliess. In 1864, Laborde^ 
asserts that but four autopsies are known to science — the two 
made by Rilliet and Barthez, one by Fliess, and one by Duchenne 
and Bouvier. To these he added the two that formed the basis 
of his ovm monograph. In 1867, Dr. Taylor, of New York,^ 
observes that nothing satisfactory has been.- discovered in regard 
to the pathological anatomy of infantile paralysis. In 1871, 
Gerhardt-^ quotes only four cases — those of Hutin, Longet, 
Behrend, and Recklinghausen. In 1870, Meigs^ quotes these 
four, the two of Laborde, and one by Hammond {Journ. of Psych. 
Med., 1 851), and is unacquainted with any others. In 1868, 
Radcliffe quotes six cases, and affirms them to be all negative in 
result, including the two of Laborde. ^ 

In 1872, Smith, basing his opinion upon the same cases, says 
that nothing satisfactory is known. '^ Finally, as late as 1873, 
Adams ^ asserts that only three autopsies have been recorded — 
the two by Rilliet and one by Fliess, to which he adds one by 
himself, also negative in character. Since Laborde's cases in 
1864, I am aware of fourteen that have been published, and of 
these only two, one by Hammond and one by Adams, are known 
to or at least mentioned by the authors just named. In the real 
or supposed absence of sufficient data to form a positive theory, 
conjecture has run wild in framing hypotheses. In regard to 
them, it is useful to recognize three distinct phases of opinion, 
corresponding to successive anatomical discoveries. 

In the first period, opened by Underwood, in 1789, the disease 
was defined as essential, i.e., as unaccompanied by any structural 
lesion whatever. This is the well-known opinion of Rilliet and 
Barthez, and is maintained at much later dates by Kennedy,' 

» Die Kinderldhmung, i860. Zweite Auflage. 

' Paralysie de I'Enfance, 1864. 

3 On Infantile Paralysis and resulting deformities. 

* Lehrbuch der Kinderktankheiten, 187 1. 
s Diseases of Children. 

* Reynold's System of Medicine. t Diseases of Children. 

* On Club Foot. » Dublin Quarterly, 1850. 



242 Mary Putnam Jacobi 

West,' Bierbaum,^ Vogel,^ Bouchut,'' Ketli,^ Politzer,^ Elischer,' 
Barwell/ Braun,' and Adams,'" the last seven authors having 
written at various dates between 1871 and 1873. Barwell rather 
emphatically denounces the existing excessive tendency to local- 
ize infantile paralysis in the spinal cord, and reaffirms the essent- 
ial, functional, peripheric nature of the disease. On the other 
hand, Drs. Taylor," Smith, and to a certain extent Meigs 
imitate, to-day, the reticence of Marshall Hall,'^ in 1836, who 
declared himself, from lack of testimony, unable to form an 
opinion. Roth,'^ who gives a careful resume of several autop- 
sies, and even Cornil,"' who has himself contributed one of the 
best known, continue this reserve. 

Brown-Sequard, in 1 860' ^ and 1861,'^ classed the "so-called" 
essential paralysis of children, among reflex paralyses, dependent 
upon peripheric irritation, and characterized anatomically by 
absence of all lesion in the spinal cord. Echeverria, in 1861,'^ 
re-enunciated this doctrine, the latter part with much more 
emphasis than his master had done, and the theory was accepted 
with certain avidity by many English writers, as Churchill, Coley, 
and others, who seem to have a national preference for any theory 
of disease that evades the necessity of post-mortem examinations. 
A second modification of the essential doctrine is represented by 
Bouchut, who, from the essential paralyses, separates others 
called myogenic, on account of muscular lesions which the author 
considers primitive.'^ 

Much before this time, however, attention had been drawn to 
the spinal cord as the real seat of the infantile paralysis, and 

' Diseases of Children, 1848. Am. ed. of i860. 

' Jahrbuch fUr Kinderkrank., 1859. 

3 Diseases of Children. Transl. from fourth German edition . Raphael, 
1870. 

'^ Bull, de Therap., 1872. ^ Jahrbuch fiir Kinderkrank., 1873. 

^ Jahrbuch fiir Kinderkrank., i866. ? Quoted by Kdtli. 

* Loc. cit. 9 Compendium fur Kinderkrank., 1871, p. 161. 

'"Loc. cit. ^^ Infantile Paralysis, 1867. 

" Lectures on Nervous Syst., 1836, p. 81. 
^^ Paralysis in Infancy, Lond., 1869. 
"• Manuel d'Histol. Path., 1873, p. 637. (2e Partie.) 
's Central Nervous System. ^^ Lectures on Paraplegia. 

^1 Am. Med. Times, 1861, vol. ii, p. 315. 
'* Traits des Maladies des Enfanis, 1862. 



Pathogeny of Infantile Paralysis 243 

of some material lesion which should be its proximate cause. 
As I believe has invariably been the case in the study of diseases 
of the nervous system this lesion was at first located in its blood- 
vessels, and the paralysis attributed to a congestion of the spinal 
cord, or to hemorrhage, capillary or otherwise, into its substance. 
This opinion was advanced by Heine as a plausible conjecture, 
supported however by the assertions of Muller, Sandras,' 
Warnatz,^ and Vogt,^ and with the autopsy of Fliess.'' It was 
reaffirmed by Eulenburg in 1859,^ although in his treatise on 
Nervous Diseases published in 1872, he is much less positive. 
He assigns a central origin to the paralysis, but will venture no 
conclusions concerning the nature of the lesion. Brunniche* and 
Radcliffe,'' on the other hand, do not hesitate to describe this 
lesion as congestion, and Adams admits a slight congestion as the 
only alternative to the theory of purely functional alteration. 

Dr. Jacobi, in his lectures on dentition, partly combated 
Heine's theory as too exclusive, nevertheless inclined to admit its 
correctness in a large number of cases, and even assumed a 
spinal hemorrhage as the lesion which would correspond most 
completely to the symptoms, and especially to the mode of in- 
vasion of infantile paralysis. Mauthner, in 1844,^ knew no 
other cause for sudden paralysis in children than cerebral or 
spinal apoplexy. 

In the Lancet for 1870, Clifford Albutt emphatically rejects 
a "reflex" origin for infantile paralysis, and ascribes the disease, 
in some cases at least, to spinal hemorrhage. He relates a case, 
not however of infantile paralysis, but of hemorrhage into the 
cervical cord, of which the child immediately died. Hayem, ' in 
his thesis on Intra-rachidian Hemorrhages, repeats this case, 
and observes that, had the hemorrhage occurred in the lumbar 
instead of the cervical cord, the child might have survived and 
offered an apparently typical case of infantile paralysis. 

Finally Salomon, in 1868/° ascribes the paralysis to an 

' Schmidt's Jahrbucher, Bd. 80. 

' Schmidt's Jahrbucher, Bd. iv., suppl. 

3 Die essentielle Ldhmung der Kinder, Bern, 1 858. 

* Journal ftir Kinderkrankheiten, Bd. xiii. ^ Archiv. Virch., 1859, 

6 Loc. cit. 7 Loc. cit. 

^ Die Krankheiten des Cehirns und Riichenmarkes bei Kindern, 1844. 

9 These de Concours, 1872. ^'> Journ. Jiir Ktnderkrank,, 1868. 



244 Mary Putnam Jacobi 

"exsudation process " in the spinal membranes, by which the cord 
is more or less compressed. 

In a third period, researches have been made upon the nervous 
elements of the cord — researches for the first time conducted by 
means of the microscope — and which have founded an entirely 
new school of doctrines concerning infantile paralysis. Yet in 
this school are several different sects. Laborde originally located 
the lesion in the anterior columns and anterior roots, and is sup- 
ported in this by Cornil, who communicated a case to the Soci^t6 
de Biologic in 1863. Gerhardt follows the French pathologists,^ 
and Meigs ^ admits sclerosis of the anterior columns and roots to 
be, at least, a coincidence in cases of long standing. On the other 
hand, Charcot, ^ Joffroy, Parrot, Prevost, '' Vulpian, ^ Roger, and 
Damaschino, ^ and Lockhart Clarke^ affirm, as the result of new 
autopsies published by them, that the essence of infantile paraly- 
sis consists in an inflammatory atrophy of the cells in the anterior 
horn of gray substance, especially on its outer side. On the 
authority of these same autopsies, this view of the disease is 
admitted as highly probable by Meyer^ and Volkmann^ in Ger- 
many, Hillier'" in London, Hammond" in New York. In Paris, 
Duchenne, father" and son, '^ had, in 1861 and 1864, advanced 
nearly this theory as a most plausible hypothesis, * •* before ana- 
tomical demonstration could be obtained, and ranked infantile 
paralysis with the spinal paralysis of adults, and even with its 
acute ascending form, and also with glosso-labio-pharyngeal 
paralysis. But since the publication of these facts, Dujardin 
Beaumetz has placed infantile paralysis among cases of acute 
myelitis,'^ and Hallopeau has described infantile paralysis as a 
form of myelitis, to be associated closely with progressive muscu- 
lar atrophy, as a parenchymatous inflammation of the anterior 
gray substance, and thus notably distinguished from the diffused 
inflammations that affect the neuroglia and result in sclerosis. ' ^ 

' Lehrbuch fur Kinder krankheiten, p. 699. ^ Loc. cit. 

3 Archives de Phys., 1870 Revue Phot., 1872. 

•» Comptes rendus Soc. de Biol., 1866. s Archives de Phys., 1870. 

« Gaz. Med. ,1871. ' Med. Chir. Trans. , 1 868. 

* Journ. fiir Ki^iderkrank., 1868. 

9 On Electricity. Translated by Hammond. 

»» Loc. cit. " Loc. cit. " Diseases of Nervous System, 

^i Electris. local., 1861. '* Archives Gen., 1864. 

'iDe la Myelite Aigue, These de Concours, 1872. '^Archives Gen., 1871. 



Pathogeny of Infantile Paralysis 245 

"If," he writes, "we have been able to localize in the posterior comua 
the organ of locomotor ataxia., in the same manner we have the right to con- 
sider the anterior gray substance as the central organ of muscular atrophy- 
Wherever this exists alterations of the anterior horns have been found on 
competent microscopic examination; and these amyotrophic lesions are to be 
attributed to the same cause, whether they appear in the course of a diffused 
myelitis, or under the form of progressive muscular atrophy or of infantile 
paralysis." 

So Charcot, in his Lessons on the Nervous System, classes 
together hematomyelie, acute central myelitis, and infantile 
paralysis, as peculiar irritative affections of the central gray 
substance of the spinal cord, necessarily resulting in muscular 
atrophy. In these affections, of which infantile paralysis is the 
most perfect type, everything leads to the belief that the primi- 
tive lesion is in the nerve cells, as distinguished from the neuroglia 
and reticulum of nerve fibres.^ Vulpian announces the same 
doctrine in his Cours de VEcole de Medicine. In the Revue Photo- 
graphique for the same year is published a lecture by Charcot 
upon the group of myopathies of spinal origin, a group almost 
exactly corresponding to that framed in 1861 by Duchenne. 
Finally, encouraged by this definite declaration of doctrine on the 
part of the illustrious master, Petitfils has sustained, in 1873, 
an inaugural thesis under the title, acute atrophy of motor cells, 
which is described as the primitive lesion universally existing in 
the diseases of this group, namely, glosso-labio-pharyngeal para- 
lysis, progressive muscular atrophy, general spinal paralysis of 
the adult, and infantile paralysis. ^ 

Nothing can be more complete than the opposition between 
this opinion and that formerly given, and which has so widely 
prevailed, that every writer on the subject has felt obliged to refer 
to the disease as either essential, or at least as the "so-called" 
essential paralysis of children. 

Since the change of opinion — which, however, is yet very far 
from universal, even among competent authorities — is based 
on the results of autopsies, it is necessary to examine these results 
in detail to ascertain how far they justify such a revolution, or 
what objections may be made to them. 

' Legons d la Salpetrihre, 1872. 

' These de Paris, 1873. Considerations sur I'atrophie aigue des cellules 
motrices. 



246 Mary Putnam Jacobi 

The appearances described are referred either to the paralyzed 
muscles, the spinal cord, or both, and may be grouped into three 
classes. In the first nothing was found; in the second, atrophy of 
muscles, and lesions discovered in the cord, that, however, 
offered no peculiarity corresponding to the peculiar symptoms of 
infantile paralysis; in the third, finally, lesions were found involv- 
ing one or more of the peculiar elements of the cord, and ana- 
logous to those discovered in other cases of disease, which 
resembled infantile paralysis in loss of voluntary motion, and in 
atrophy of the muscles paralyzed. 

1st. Negative Autopsies. — There are seven autopsies on re- 
cord, whose results are said to be completely negative. Of these, 
three — Rilliet's,' and one by Duchenne and Bouvier, may 
be immediately set aside, since it is admitted that no microsco- 
pic examination was made. We think that to-day it would be 
superfluous to observe, as a recent English writer does with con- 
siderable naivete, that "the researches of Mr. Lockhart Clarke 
have shown that the microscope may he of very great assistance 
in unravelling the pathology of the spinal cord." A fourth 
negative case is that reported by Mr. Adams, in his Treatise on 
Club-foot. He says, that after a very careful examination, he 
was unable to detect any morbid condition of the spinal cord, but 
does not specify whether the examination was microscopical, nor 
how long a time had elapsed since the occurrence of the paralysis. 
A fifth case, more important, was published by Bouchut, in the 
Union Medicale for 1867, where a microscopial examination, made 
by Robin, could discover nothing in the cord. Finally, in a very 
recent number of the Jahrbuch fur Kinderkrankheiten for 1873, 
Ketli quotes two autopsies made by Elischer upon paralyzed 
children who had succumbed to variola. Microscopical examin- 
ation of the cord gave completely negative results, but the 
muscles offered examples of two kinds of degeneration, the fatty 
and the colloid. Ketli considers these the most exhaustive re- 
searches that have been made, and as completely justifying 
Bouchut's description of myogenic paralysis, characterized by 
primitive granular fatty degeneration of muscular fibre. This 
view is analogous to that advocated by Friedreich in regard 
to progressive muscular atrophy, a disease so frequently associ- 
ated with infantile paralysis by authors who assign a central 

*Gaz. Med., 1851. 



Pathogeny of Infantile Paralysis 247 



nervous origin to both. ^ The latter authors are nearly all more 
recent than the former. 

Among the six negative cases, therefore, while four are im- 
portant, only one can be considered completely satisfactory — 
that reported by Bouchut. 

Of the next seven cases, five are old, among the first on record. 
They are repeated in almost every monograph or chapter on 
infantile paralysis. The first case is recorded by Longet in a girl 
with a club-foot, who died at the age of eight, the muscles, sciatic 
nerve, and its anterior roots on the corresponding side, were all 
atrophied. In the second case, from Hutin, paraplegia occurred 
at 7 ; death at 45 ; and at the autopsy the lower part of the cord 
was found atrophied. In the third and fourth cases the paralysis 
was evidently secondary to general organic disease of the cord; 
in the one case spinal meningitis (Behrend), in the other tubercle 
(Recklinghausen). These latter cases can only show that 
pressure exercised upon the cord may produce paralysis whenever 
the motor organs of the cord have become involved. They, of 
course, cannot be involved as most frequent explanation of 
ordinary infantile paralysis. The two cases of simple atrophy 
correspond to the lesions found after section of nerves. 

The fifth autopsy of this class is that so often quoted from 
Fleiss, recorded in the Journal fiir Kinderkrankheiten for 1849. 
A child, 5 years old, having passed a restless night, was found 
in the morning with the left arm paralyzed. No adequate 
cause for the paralysis was discoverable, but the examina- 
tion showed in the mouth some decayed milk-teeth. A few 
days later the child was killed by a kick from a horse, and at the 
autopsy was seen a notable dilatation of blood-vessels around the 

' Friedreich gives the following table of authors in two classes, of which 
the first assigns a muscular, the second a nerval, origin to the disease. 

Nerval 
Romberg. Lehrbuch fiir Nerven- 

krank. 
Fromman. Deutsche Klinik, 1857. 
Virchow. Handbuch, 1854. 
Jaccoud. Chir. Med., 1867. 
OUivier. These de Concours, 1869. 
Erb. Deutsches Archiv. 1867. Bd. v. 
Trousseau. Chir., 1868. 
Charcot Arch, de Phys., 1869. 
Clarke Med. Trans., 1 866-1 868. 
Hayem Arch, de Phys., 1869. 



Muscular 
Meryon. Med.- Chir. Trans., 1852- 

1866. 
Wachsmuth. Zeits. f. rat. Med., 

1855-. 
Oppenheimer. Ueber prog. fett. 

musk, 1855. 
Hasse. Krankheilen des Nerven 

Syst., 1869. 
Meyer. Wiener Wochenschrift, 1855. 
Friedberg. Pathol, und Therap. 

Mus. kelldhm., 1858. 
Roberts Wasting Palsy, 1858. 



248 Mary Putnam Jacobi 

roots of the left brachial plexus. This vascular turgescence 
extended to the shoulder, the neck, and submaxillary region. 

The cerebral meninges were congested, as a result of the 
blow. No microscopic examination was made of the cord. 

Fleiss attributes the congestion to the irritation of the de- 
cayed teeth, and the paralysis to the pressure of the dilated 
blood-vessels upon the roots of the brachial plexus. The ex- 
amination was too incomplete to permit this explanation to be 
accepted as decisive; but this case, like those of Longet and 
Hutin, offers no contradictions with later autopsies. 

The sixth case is reported by Hammond in the first* volume 
of the Journal of Psychical Medicine. Paralysis of the left 
leg had lasted four years, and at the autopsy was found an en- 
cysted clot, in the left anterior column of the lower part of the 
dorsal region. The history of the debut of the disease is not 
given, nor are we told whether the cord showed any evidence of 
myelitis, or to what symptoms the patient succumbed. 

It is remarkable that this is the only case of infantile paraly- 
sis in which evidences of a circumscribed hemorrhage have been 
found in the cord. The case related by Clifford Albutt is the 
following: A healthy child of seven months was lifted up 
rather roughly by the mother, fell forward heavily in her arms, 
and a few minutes later was paralyzed in its four limbs. Death 
occurred by paralysis of the respiration, and at the autopsy 
were found two hemorrhagic clots in the cervical spinal cord, 
the smaller in the left posterior horn, the larger in the right 
posterior. 

In quoting this case, Hayem refers to another, the seventh in 
our series, where, in a person of twenty-four years of age, who 
had been paralyzed when two years old, he found an infiltrated 
hemorrhage in the lumbar cord. ^ 

The third class of autopsies of presumed infantile paralysis, 
are all recent, and include twelve cases, in all of which some 
lesion was found in the spinal cord. 

The first autopsy was published by Comil in 1863. A wo- 
man of forty-nine had become paraplegic at two years of age, 
and could not walk for six years. After that, was enabled to 

' Journal of Psychical Medicine, vol. i. , p. 51. 

^ A table of these same cases has been published by Dr. E. C. Seguin, in 
the N. Y. Medical Record for last January. 



Pathogeny of Infantile Paralysis 249 

walk, though painfully, by means of the muscles of the thighs, 
although those of the leg and foot were atrophied, especially 
on the left side. This false restoration of motor power I have 
observed many times myself. After death by cancer of the 
pleura, the autopsy discovered complete fatty substitution of 
the muscles of the left leg, and incomplete on the right ; atrophy 
and fatty degeneration of the sciatic nerves, and diminution 
in the thickness of the anterior columns of the lumbar cord. A 
great number of amyloid corpuscles were strewn through the 
anterior columns. The cells of the comua were intact. 

The next two are those often quoted, published by Laborde 
in 1864, in which the anterior columns of the cord, translucid 
to the naked eye, were found by microscopical examination to 
be extensively sclerosed. In the mass of conjunctive elements, 
the nerve tubes had atrophied, many had completely disap- 
peared, many that remained were varicose. This was especially 
noticeable in the first case, a child of two years, who at the age 
of eight months, after a short fever, was seized with general 
paralysis, soon limited to the lower limbs. In the second case 
the child had fever and repeated convulsions at a year old, then 
became paraplegic. Before death, a year later, atrophy and 
consequent deformity had made much progress. In this case 
death occurred from pneumonia, and at the autopsy was found 
a remarkable vascularization of the spinal pia mater, and of the 
superficial part of the anterior column. The nuclei of the capi- 
laries were multiplied, and the walls of these vessels surrounded 
by exsudation corpuscles, which also were infiltrated in great 
numbers among the nerve tubes. The latter were varicose 
and broken in many places, in many others had entirely dis- 
appeared. In both autopsies the elements of the comua were 
noted as perfectly healthy, as were also those of the paralyzed 
muscles. 

The fourth autopsy is by Prevost in 1866 (Soc. Biol.). The 
history of the paralysis could not be obtained, but at 78, the 
time of death, the left leg was paralyzed, muscles soft and flaccid, 
the foot in talipes calcaneus. After death these muscles were 
found to be completely converted into fat. The inter-muscular 
nerve-fibres were unaltered. In the nervous centres, besides 
a recent purulent cerebro-spinal meningitis, not diagnosed 
during life, was found a marked atrophy of the anterior horn 



250 Mary Putnam Jacobi 

on the left side. The external portion was converted into con- 
nective tissue, colored red by carmine, and in whose meshes 
hardly a nerve-cell was to be found. The nerve tubes in the 
columns or the anterior roots were intact. 

The fifth autopsy belongs to Lockhart Clarke, and is published 
in the Medico-Chirurgical Transactions for 1868, as a case of 
progressive muscular atrophy. The symptoms are those of infan- 
tile paralysis ; the lesions similar to those found by the author in 
cases of the latter disease, and consist in foci of granular disin- 
tegration in the anterior cornua of the cord, and where the nerve- 
cells had disappeared. 

The sixth case was communicated by Charcot and Joffroy to 
the Soc. de Biol, in 1869. Sudden general paralysis occurred 
at seven years, accompanied by a transitory loss of speech. A 
certain weakness persisted in the four limbs, which amounted to 
permanent paralysis in the left arm. Death at 32. At the 
autopsy was found, in the entire length of the cord, a marked 
alteration of the anterior cornua, with integrity of the anterior 
columns. In the cornua the motor cells had extensively disap- 
peared, and been replaced by conjunctive tissue. This alteration 
was chiefly marked in the cervical region on the left side. 

The seventh case is from Vulpian, and is detailed in the 
Archives de Physiologic for 1870. Here, as in Prevost's case, was 
no history. At 66, age of death, the left leg was atrophied and 
paralyzed, and there was a coxo-femoral dislocation, which the 
patient affirmed existed from infancy. After death the para- 
lyzed muscles were found to be converted into fat, and the 
spinal cord, scarcely altered to the naked eye, showed under the 
microscope a species of atrophy of the gray substance in lower 
lumbar cord, and a species of sclerosis of the right anterior horn. 
At this point the section was less colored by chromic acid, more 
by carmine; the majority of the nerve-cells in the external 
path of the horn had disappeared, and their place was occu- 
pied by new connective tissue, and enlarged blood-vessels. Be- 
sides, there was very superficial sclerosis of the anterior columns. 

The eighth case appeared also in 1870, and is by Parrot and 
Joffroy. The autopsy was made on a child of three years, com- 
pletely paralyzed in the left lower extremity, incompletely in 
the right. The paralyzed muscles contained an abnormal quan- 
tity of conjunctive tissue, but were not fatty. The alterations 



Pathogeny of Infantile Paralysis 251 

of the anterior horns in the lumbar were precisely similar to 
those of Vulpian, and their relative extent on the right and left 
side corresponded to the degree of paralysis. There was no- 
ticed besides, atrophy of the axis cylinders constituting the 
nervous reticulum, to be distinguished from that of the neurog- 
lia; atrophy and sclerosis of the anterior columns; and altera- 
tion of vessels, whose lymphatic sheaths were crowded with fat 
granules. The sclerosis coincided in extent with the lesions of 
the cornua, but the alterations of the vessels extended much 
further up the cord. 

In 1 871 appeared the memoir of Roger and Damaschino, 
containing the record of three new cases. In the first case, left 
hemiplegic paralysis at two years old, rapidly limited to the 
left deltoid, which became much atrophied. Death two months 
later of hemorrhagic scarlatina, during which an attack of para- 
plegia, principally at the right. The deltoidwas found in 
simple atrophy; the left anterior cervical roots congested and 
atrophied, and in the cord various foci of alterations in left an- 
terior cervical, and also in the right lumbar region. The mi- 
croscopic lesions resembled those just described; the cells were 
atrophied, and nerve tubes in the roots deprived of myeline; 
the vessels were dilated, and their walls covered with fatty 
granulations, and the anterior columns were sclerosed; this 
about equally on the two sides. The atrophy of the roots ex- 
tended all along the cord. The foci of alterations were softened 
and visible to the naked eye. 

In the second case paraplegia occurred at two years, during 
a discrete variola. Death six months later of broncho-pneumo- 
nia. Examination of muscles showed some degree of fatty sub- 
stitution; of the cord, two foci of softening in the anterior part of 
the gray substance of lumbar region, one two millimetres in 
diameter, another larger. In these foci the tissue was almost 
diffluent, the microscopic lesions the same as in the other cases 
and these extended to three and a half centimetres above, where 
no alteration was visible to the naked eye. The fatty degener- 
ation of the blood-vessels was excessive, a reticulum of conjunc- 
tive fibres occupied the centre of the focus, from which the 
cells had disappeared, and this was surrounded by a true cyst 
wall. No distinct hemorrhage complicated this circumscribed 
myelitis. The anterior columns were sclerosed. In the third 



252 Mary Putnam Jacobi 

case, a child of three years died thirteen months after the inva- 
sion of paraplegia, with the ordinary symptoms. Foci existed 
in the lumbar region similar to those in the preceding case, 
and surrounded also by indurated conjunctive tissue. But mi- 
croscopic lesions of the anterior cornua and columns extended 
all along the cord. 

On account of these complex alterations — degeneration of 
blood-vessels, formation of exsudation corpuscles, atrophy of 
nerve cells and tubes, hyperplasia of conjunctive nuclei, sec- 
ondary sclerosis of anterior columns, — the authors admit a my- 
elitis starting, not from the motor cells, as Charcot would have 
it, but from the interstitial tissue of the cord. 

The twelfth observation is due to Lancereaux, and is published 
by Petitfils in his Thesis for 1873. Paralysis of the left arm at 
two or three years old, resulting in considerable atrophy. Death 
at 18. The muscles were found in simple atrophy, the left an- 
terior horn was atrophied in the cervical region, from disappear- 
ance of external group of motor cells, and substitution of con- 
junctive tissue. A certain amount of atrophy existed in the 
left half of the lumbar region. There was no antero-lateral 
sclerosis. 

From comparison of these twelve observations, by far the 
most important on record, it results that five lesions have been 
found in the cord in cases of unquestioned or presumed infantile 
paralysis, ist. Atrophy of the nerve cells occupying the external 
portion of the anterior horn, and atrophy of the nervous reticu- 
lum formed by their prolongations.' This in nine cases. 2d. 
Atrophy of the anterior roots, and sclerosis of the anterior col- 
umns, observed alone in the three first cases of this series pub- 
lished, and coinciding with cellular atrophy in four of the other 
cases, most marked in the three that offered foci of softening. 
3d. Proliferation of conjunctive nuclei, occupying the place 
of the nerve cells; in the nine cases these were atrophied. 
4th. Dilatations of the blood-vessels, and fatty degeneration of 
their walls, described, 'in four cases. It is quite possible that 
these existed in some of the others, where they are not de- 
scribed, because they had not been expected. 5th. Distinct 
foci of softening limited to the anterior cornua on the side cor- 
responding to the paralysis, and proportioned in extent to the 

' See Boll. Archiv fur Psychiatric, 1873. 



Pathogeny of Infantile Paralysis 253 

degree of paralysis. These only described in the three observa- 
tions of Roger and Damaschino, where the autopsy was made 
two, six, and twenty-three months after the occurrence of the 
paralysis, and when death had been occasioned by febrile dis- 
ease. In the two last the focus of softening surrounded by an 
indurated border, which had not had time to develop in the 
first case. 

On the whole, therefore, the number of cases of infantile par- 
alysis, in which lesions of the motor sections of the cord have 
been found, greatly preponderate over the negative cases. All 
recorded cases with microscopical examination, must, however, 
be taken into account, and their variations must be explained 
by variations: ist, in the form of the disease; 2d, in the length 
of time intervening between the paralytic accidents and the 
autopsy. 

Different cases of infantile paralysis vary: ist, in their mode 
of invasion; 2d, in their march; 3d, in the age of the subjects. 

In regard to the mode of invasion of paralysis in children, I 
have distinguished nine distinct forms, most of them noticed 
among the thirteen cases observed by myself, and twenty-four 
selected at random from the collection at Dr. Knight's hospital. 

In the first, the paralysis is absolutely sudden, occurs in the 
day-time, in the midst of health, while the child is under com- 
petent observation. These cases, often represented as typical, 
are in reality the rarest of all — only twelve out of one hundred 
and sixty-three cases. I have not seen one, nor is one recorded 
in West's table of thirty-two cases. There is one among Dr. 
Knight's cases, four in Hillier's table of twenty-four, and seven 
among the seventy cases tabulated by Duchenne fils; giving a 
total of twelve in 163 cases. It is well known that the severity 
of the paralysis bears no relation to the mode of invasion, or 
these cases might be supposed to be the mildest, which is not, 
however, true. 

In the second form, much more frequent, the paralysis is dis- 
covered in the morning, after a perfectly quiet night ; eight cases 
out of my thirty-seven were of this class. 

These recall the phenomena of spinal congestion, as described 
by Brown-Sequard, where the paralysis is aggravated by recum- 
bent position, on account of the gravitation of blood to the 
spinal meninges, and also by the first assumption of the vertical 



254 Mary Putnam Jacobi 

position, owing to the descent of cerebro-spinal fluid. The latter 
circumstance, however, would have no influence except in par- 
alysis of the lower extremities. 

In the third form febrile symptoms occur, generally begin- 
ning in the evening and lasting all night, or else two to three 
days. When the fever is slight, these cases closely resemble the 
morning paralysis of the second class. Eleven of Duchenne's 
cases were of this form. He says that the older the patient the 
greater is the duration and severity of the fever. 

In the fourth form the paralysis is preceded by convulsions 
instead of fever. This in four of my thirty-seven cases. 

In the fifth class the paralysis occurs in the course of another 
disease. In one of my cases the paralysis was observed after 
the child had been long kept in bed with purulent conjunc- 
tivitis; in two others occurred suddenly during an attack of 
cholera infantum. In one of Roger's cases, a child, already 
paralyzed in the left deltoid, became paraplegic during the he- 
morrhagic scarlatina that caused her death, and at the autopsy, 
nineteen days later, a focus of softening was found in the 
lumbar region of the cord, presenting the same microscopic 
lesions as the cervical focus that corresponded to the deltoid 
paralysis. 

In a seventh class the paralysis is preceded alone by vomit- 
ing. I had two cases of this kind, in one of which the vomiting 
lasted two weeks and was followed by crossed hemiplegia. 
This case might at first be attributed to a cerebral origin, but 
eight years later, the muscles were atrophied without retraction, 
and failed to contract under faradaic electricity. 

In an eighth class some mechanical accident has occurred. 
In none of the cases I have examined was the paralysis immedi- 
ate, but preceded by accidents that were the more direct conse- 
quence of the paralysis. These are easily overlooked, without 
special inquiry. Thus in one of my cases, the mother asserted 
at first that the child had been paralyzed ever since he fell 
down stairs, but afterwards admitted that he was in bed a week, 
with high fever, before the paralysis was noticed. 

Only two other such cases are on our list: in one, the child 
nearly fell from its nurse's arms, was caught violently by the 
lower extremities, and became paraplegic about a month later; 
in the other, fell from a wagon, and was lame in two days. In 



Pathogeny of Infantile Paralysis 255 

all statistics mechanical accidents are very much in the minor- 
ity, a fact in striking opposition to their frequency in the etiol- 
oly of meningeal or medullary hemorrhage. 

We separate a ninth class, in which, with the usual debut of 
infantile paralysis, symptoms are observed whose absence is 
generally conspicuous. This is a more important class than the 
others. In one of our cases the child, at the age of two and 
a half years, had a febrile attack, during which a physician pre- 
scribed morphine, after which she slept uninterruptedly for 
twenty-four hours. On awakening, she was found to be com- 
pletely paralyzed and anaesthetic in both lower extremities. 
For two days she remained insensible to the prick of a pin, and 
for eight days suffered from retention of urine. This case re- 
sembles lumbar myelitis. In another case, paralysis of the left 
leg was preceded for two days by vague indisposition, and ac- 
companied by fever, retention of urine, opisthotonus, and general 
hyperaesthesia. The absence of any modification of the sensi- 
bility, or of the action of the bladder, in the great majority of 
cases of infantile paralysis, renders the occasional presence of 
such symptoms all the more important. One similar case is 
recorded by West, and two by Hillier. 

Although theoretically superfluous, it is often practically use- 
ful to remember, that in a tenth class of cases, the paralysis is 
either congenital, or has been accompanied by marked cerebral 
symptoms, or has existed at first under the form of hemiplegia, 
together with facial paralysis; and in the two last, if not in all 
three cases, is of cerebral origin, and therefore radically differ- 
ent from true infantile paralysis. 

Among the thirteen cases seen by myself, twelve had been 
diagnosed as infantile paralysis by other physicians, and of 
these one was congenital and three certainly cerebral. I have 
based the diagnosis in the latter cases on the following points. 
First, on the form of the paralysis, which I have never seen 
hemiplegic, unless the facial nerve had been involved at the 
beginning. 

Duchenne fils gives only one case of hemiplegia, that is not 
described, and two cases of cross hemiplegia, the latter admit- 
ted to be excessively rare. Heine apparently makes a class of 
nine cases, but in only one did the paralysis involve an upper 
and lower extremity. It followed a fever of several days, and 



256 Mary Putnam Jacobi 

as Heine did not see the case till years afterwards, a facial par- 
alysis might easily have been overlooked by the parents. 

In two of West's cases the hemiplegia was congenital, in two 
it involved the face, in seven the paralysis was limited to the 
facial nerve; in five alone was it confined to a leg and arm of 
one side. In two of these it came on gradually; in one suc- 
ceeded to remittent fever; in one was preceded by heaviness of 
the head for several days, and in one the leg was paralyzed 
fourteen days after the arm. 

Although, therefore, the hemiplegic form cannot be said to 
absolutely exclude infantile paralysis, it is so exceptional as 
to offer a strong presumption against the existence of that dis- 
ease. The second point of diagnosis is the coincidence of cere- 
bral symptoms other than the facial paralysis, which certainly 
must be considered as such. It is curious how often these 
may be detected in quite a small range of cases. Thus: in 
one, the hemiplegia appeared after coma during cerebro-spinal 
meningitis. In a second, after a violent convulsion, the face 
was spasmodically drawn to the opposite side, and the patient, 
a child of seven, remained for a month in a state of intense 
maniacal excitement. In a third, developed during convales- 
cence from scarlet fever, the hemiplegia was preceded by paresis 
during two days, and accompanied for a year by complete 
aphasia. In the fourth case, where the child, who had presented 
transversely at birth, offered a paralysis of the muscles of the 
forearm, principally, and by exception, seated in the flexors, 
so that the hand was bent back on the wrist, the extreme localiza- 
tion of the trouble was a point of much resemblance with infan- 
tile paralysis, or, as the arm had prolapsed during labor and been 
replaced, the paralysis might also have been attributed to a 
peripheric traumatism. But the first hypothesis was contra- 
dicted by the presence of an anaesthesia so complete that the 
child constantly chewed the ends of her fingers, and the second 
was equally opposed by the complete preservation of faradaic 
contractility. The reactions to the faradaic current are well 
known to constitute an important means of diagnosis between 
cerebral paralysis on the one hand, and those of peripheric or 
spinal origin on the other. The value of this test has been much 
disputed, but is, we believe, to-day generally admitted. 
Duchenne, giving greater precision to the ideas of Marshall 



Pathogeny of Infantile Paralysis 257 

Hall, claims to have discovered this test. Bouchut disputes 
the claim to priority, but admits the value of the test. It is 
very remarkable, that in infantile paralysis the loss of fara- 
daic contractility is as rapid as is loss of power to respond to 
electricity after section of a nerve — namely, in thirty-six hours 
according to Harwell, in six to eight days according to Duchenne. 
Salomon * has especially investigated this matter, and has en- 
tirely confirmed the views of Duchenne, except in regard to the 
absolutely bad prognosis that is implied by complete loss of con- 
tractility. It was necessary for Hammond and Radcliffe to 
discover, as a new fact, that the muscles which failed to react 
to the faradaic current, would often, though not always, re- 
spond to galvanism. In thirty-seven cases that I have ex- 
amined, all of whose histories contained other indication of cere- 
bral origin, normal faradaic contractility persisted after years 
of paralysis and excessive atrophy. The same is true of those 
singular cases of congenital paralysis accompanied by rigid 
muscular contractions. In all cases on the other hand, where 
such cerebral symptoms were absent, the muscles completely 
failed to contract, although their helplessness, atrophy, and 
flaccidity were not greater than in the first case. Since in mus- 
cles atrophied after long standing cerebral paralysis, faradaic 
contractility persists, and since this completely disappears in 
infantile paralysis long before atrophy has set in, the phenom- 
enon is clearly independent of the condition of the muscular 
fibre, and must be connected with that of the nerves. It is ob- 
served m diffused chronic myelitis, as well as in infantile para- 
lysis, and Vulpian concludes that lesions of the cord determine 
in nerves alterations in structure similar to those observed in 
their peripheric end after section. 

It has seemed to me that the possibility of exciting contrac- 
tions by a very slow interruption of a strong induced current, 
does not always imply return of power to the nerve. In one case, 
where, after two days' convulsions, paralysis of the right arm 
had occurred, soon limited to the deltoid, where it was persist- 
ing two years later, an ordinary induced current gave no con- 
tractions whatever, but these were obtained with galvanism; 
and also when the secondary induced current was very slow 
and jerking, and applied directly to the muscle instead of through 
^ Jahrbuch fiir Kinderkrankheiien, 1868. 



258 Mary Putnam Jacobi 

the nerve. But after months of treatment with this current, 
the paralysis remained unimproved. 

Another sort of fallacy is due to the derived currents, which 
excite contractions in antagonistic muscles, that are often mis- 
taken for movements in those through which the current is 
passing, and which really are too much paralyzed to respond. 
Thus I have often seen the toes move as the common extensor was 
faradaized, but it was evident that they moved only in flexion, 
precisely as when the current was passed directly through the 
flexors themselves. 

Paralysis following diphtheria or other febrile blood dis- 
eases, as described by Gubler, must also be separated from real 
infantile paralysis. Many cases are really due also to different 
accidents than the one to which they are attributed. Thus S. 
Weir Mitchell describes a case where a child, shortly after a 
fall, was found to be lame in the right leg; but it was discovered 
at the same time that decided atrophy of the muscles already 
existed, and it was shown that the nerves of the lumbar plexus 
were compressed by exsudations that had formed during a severe 
attack of typhlitis. 

In regard to the march of the disease, three principal varie- 
ties are to be distinguished: in the first, the paralysis completely 
disappears, either spontaneously or after treatment, in from 
two days to a few months. Kennedy's famous cases are of this 
description. Barwell asserts that the majority of cases that came 
under his observation, are curable when treatment is begun 
shortly after the debut of the paralysis. A similar assertion is 
repeated by Hitzig and Jurgensen' in opposition to the ex- 
tremely unfavorable prognosis of Volkmann. For the personal 
knowledge of one such case, I am indebted to Dr. Jacobi. A 
lady, affected with chronic endometritis, miscarried several 
times from fatty degeneration of the placenta. At the first 
living birth the placenta was found to be still partly fatty, 
and the child was subject for two years to repeated intestinal 
hemorrhages. These were attributed to an imperfect structure 
of blood-vessels, analogous to that existing in the placenta. 
At the age of two years the child was found paraplegic one 
morning upon awakening. No anaesthesia. In three to four 
days the paralysis was limited to the muscles of the right leg; 

' Archivfur Deutsche Klinik, 1873. 



Pathogeny of Infantile Paralysis 259 

in a week these still responded well to both currents. No elec- 
trical treatment was used, but ergot administered, and ice 
applied to the spine. Recovery was complete in two months. 

In the second class of cases, the paralysis, at first general- 
ized, becomes limited to a few muscles, and there persists in- 
definitely. In the third class, finally, the muscles begin very 
soon to waste, and the atrophy becomes so general and exces- 
sive that the limb dangles about like a loosely jointed stick, 
the famous "jambe de Polichinelle " of the French writers. 
These cases are too well known to require description or even 
illustration, but their frequency seems to me to have been exag- 
gerated. 

Among the twenty-seven autopsies, the muscles were exam- 
ined in fifteen; were found simply atrophied in six; replaced 
more or less completely by adipose tissue in eight; and in one 
offered no appreciable alteration. There is no well-defined 
relation between the date of paralysis and the invasion of the 
muscles by fat. It is true, one of the cases above quoted of 
simple atrophy is Roger's where the examination was made 
two months after the date of the paralysis; but on the other 
hand, Hammond has examined the muscular fibre from the 
living subject in two cases in which the paralysis had lasted 
over four years, and found the structure unchanged. Accord- 
ing to Charcot, the rapid wasting of muscular fibre within its 
sarcolemma, with persistence of the striations, is alone character- 
istic, — ^fatty substitution is always accidental. 

In regard to the third variation, that is, in the age of the pa- 
tient attacked by paralysis, it would seem at first that this is 
settled by the very designation, "infantile," "dental"; and in- 
deed, to many it is so. All records, however, contain many cases 
in which the accidents occurred after two years old, hence beyond 
the period of the first dentition. But, as previously observed, at- 
tention has been recently drawn to certain cases of paralysis in 
the adult where the symptoms completely resemble those of in- 
fantile paralysis. In 1861 already, Duchenne described cases of 
general spinal paralysis in the adult, which he considered as quite 
analogous to infantile paralysis; and in his third edition he re- 
lates four cases that differ, indeed, from infantile paralysis in the 
presence of rachialgic pains, but resemble it in the rapid inva- 
sion, primitive generalization, and subsequent limitation of the 



26o Mary Putnam Jacobi 

paralysis. In the thesis of Petitfils are recorded three cases, 
observed by Charcot, in adults. The paralysis was discovered 
in the morning, in one; after twenty-four hours hemiparesis, in 
a second; after four days vague indisposition, in a third. In 
one, paralysis was paraplegic from the beginning; in one, gen- 
eralized at first, afterwards paraplegic; in one, it successfully 
invaded the four limbs. In one there was pain ; in one anaesthe- 
sia; in one trembling. In all, faradaic contractility disappeared 
in the paralyzed limbs, which grew cold, and atrophied rapidly 
for a few weeks, then began to improve, and in one case were 
completely restored. Meyer relates two cases that have been 
quoted as examples of paralysis, but which are evidently pro- 
gressive muscular atrophy. But M. Brown-Sequard has related 
to me a case, in an adult, which entirely resembled infantile 
paralysis, with extreme wasting, which was ultimately cured. 
Cuming'' has seen a case of general paralysis, occurring sud- 
denly, after exposure to cold, with nearly all the negative symp- 
toms peculiar to infantile paralysis, but followed by darting 
pains in the lower limbs, some spasmodic contraction of their 
muscles, slight atrophy of the upper extremities, and claw hands. 
Return of power to walk in three months. I have seen a some- 
what similar case at the Mount Sinai Hospital, but of which 
the termination is still uncertain. A man, having vomited 
constantly for two weeks without presenting any other symp- 
toms, was seized with paralysis of the arms upon going to a 
pump in the court-yard. The next day the paralysis had ex- 
tended to the lower extremities, and was followed by constant 
severe pains in the paralyzed limbs. The muscles wasted rap- 
idly; nevertheless, in about three months the paralysis had 
become limited to the parts of the limbs below the elbow and 
knee-joints. A year later, the patient was still in this condition, 
the hands clawed, the feet in slight varus equinus; faradaic 
contractility abolished in the muscles that remained paralyzed. 

Still another case is related with great detail by Bernhardt, 
in the last number of the Archiv fiir Psychiatric (1873). In 
every essential respect it resembles the above, and is considered 
by the author as identical with the so-called infantile paralysis. 
A twelfth case is quoted from Lucas Championniere, in Hallo- 
peau's memoir on diffused myelitis, already referred to. Eigh- 

' Dublin Quarterly, 1869. 



Pathogeny of Infantile Paralysis 261 

teen months before death, the patient, on recovery from con- 
finement, was suddenly affected by general paralysis ultimately 
limited to the left lower extremity. She entered the hospital for 
an attack of typhoid fever, and it was then noticed that the 
muscles of this limb were extremely atrophied, and that faradaic 
contractility was abolished in them. The patient succumbed to 
the fever, and at the autopsy the muscles were found in fatty 
degeneration, and in the lumbar region of the cord, foci of soften- 
ing in the two anterior horns. These were analogous to those 
observed by Roger, also after febrile diseases, in the muscles 
that remained paralyzed. 

In the last January number of the Archives de Physiologie, 
Gombault relates a case quite analogous to these, but attended 
at first by severe rachialgia. Paralysis remained generalized for 
two years, but at three and a half years, use of the four limbs 
was incompletely recovered. Death occurred through some 
complication, and at the autopsy was found a pigmentary de- 
generation of the cells in the anterior horns, lesion generalized 
all along the cord. The anterior roots were atrophied, the an- 
terior columns, and all other parts of the cord healthy. The 
paralyzed muscles were sclerosed, and the sarcolemmae generally 
empty. This valuable autopsy may justly be classed with those 
already related of infantile paralysis. 

It appears, therefore, that the age of the patient cannot be 
reckoned as an absolutely essential circumstance to the produc- 
tion of the most typical characters of the disease. All that can 
be affirmed is, that it is much the most frequent between the ages 
of six months and two years. On comparing the symptoms of 
infantile paralysis with the results furnished by autopsies, we find 
that a certain number among both, one and the other, may be in- 
voked in favor of one or the other pathogenic theories we have 
enumerated. The sudden invasion, and occasionally complete 
spontaneous disappearance of the accidents, together with the 
negative results of four autopsies, have been supposed to prove, 
now the "essential," i.e., functional character of the disease, now 
to indicate a transitory congestion of the spinal cord. These two 
theories are often grouped together, as if supposed to be very 
nearly identical; as when Adams says that infantile paralysis is 
either a functional disease, or else depends on some slight spinal 
congestion. But in reality the two ideas are completely distinct. 



262 Mary Putnam Jacobi 

For the hypothesis of spinal congestion, so seriously defended by 
Radcliffe, presupposes at all events that the lesion, however tran- 
sitory, is central. Whereas the assertion that infantile paralysis 
is essential, functional, immediately conveys to many, and is 
perhaps meant to conve3^ the idea that only the function of the 
motor nerves is abolished, and that an essential paralysis is, 
unless reflex, essentially peripheric. Especially in regard to 
infantile paralysis has the localization of the affection been 
considered a proof that the cause of the disease was to be sought 
on the periphery of the nervous system. Now the function 
of a nerve is unique and well understood — that of conducting 
impressions. So long as these impressions, motor or sensitive, 
continue to be generated, the function of the nerve can only 
be interrupted by interruption of the road along which the im- 
pressions travel; and further, the same cause that suspends the 
conveyance of one of impression must, in the great majority 
of cases, suspend that of the other, so that a complete motor 
paralysis, dependent on an affection of a nerve, is nearly always 
accompanied by anaesthesia. It is true that this is by no means 
always in proportion to the degree of motor palsy, and a case 
related by Mitchell may be paralleled by others, where sudden 
and complete paralysis caused by dislocation of the humerus, 
was accompanied with scarcely any loss of sensation. ' Still the 
rule is the other way, and implies conditions directly opposed 
to those of infantile paralysis, where modifications of the sensi- 
bility are extremely exceptional. 

But further, from the almost mechanical nature of the 
function of the nerve, it is difficult to imagine an interruption 
to this function dependent on other than mechanical or, at 
least, physical conditions, and it is so difficult to demonstrate 
an immaterial abolition of function, that indeed it has never 
been done. It is as easy to show that wire may become imper- 
vious to the passage of electricity, unless it be severed or clogged 
by non-conducting substances, as that a nerve whose struc- 
ture is intact may nevertheless refuse to conduct impressions. 
Hysterical paralyses and anaesthesias prove nothing in regard to 
functional alterations of nerves, until it can be shown that 
the loss of motility or sensation in hj^steria be really entirely 
independent of alterations in the activity of the cells. There 

' Injuries of Nerves, p. 102 



Pathogeny of Infantile Paralysis 263 

are only five cases in which paralysis of a nerve can be posi- 
tively traced to causes confined to the nerve, when namely it 
has become inflamed, or has been severed, frozen, contused, 
or compressed. The experiments of Vulpian and Bastien, ' 
Tillaux,^ Waller, and Mitchell, have shown that in the last four 
cases the alteration of structure is as decided as in the first. 
"A nerve trunk," observes Mitchell, "is made up of a multitude 
of tubes, the contents of which are so nearly fluid as probably to 
be capable of more or less movement to and fro. When to 
such a bundle we apply a tight ligature, no matter how soon it 
be relaxed, we annihilate at once all power of the nerve to 
transmit impressions past the injured zone. After gradual and 
equal pressure the nerve is for a time incapacitated, but soon 
regains its normal abilities. It seemed to me that the reason 
for such loss and such return must be a purely mechanical 
disturbance of the tubal contents and a like mechanical restora- 
tion of their needed conditions of activity." To test this 
hypothesis, Mitchell submitted the sciatic nerve of a rabbit to 
pressure of mercury standing in a tube at varying heights. The 
conducting power of the nerve persisted until it had been pressed 
upon by twenty inches of mercury, then disappeared, but 
began to return in about fifteen seconds after removal of the 
pressure. 

It is paralysis by compression that most nearly resembles the 
hypothetical "functional" paralysis, inasmuch as an organic 
lesion is imperceptible to the naked eye. Yet it is only the 
first stage of another, which can be demonstrated after slight 
contusion of nerves. When Mitchell struck a nerve smartly 
with a smooth broad whalebone slip, allowing a thin layer 
of muscle to intervene, the paralysis which ensued, although 
often temporary, was in degree complete. In these instances 
there was usually little hemorrhage, but a few fibres were torn, 
and a large proportion suffered simply from mechanical disturb- 
ance, which gave them for a time a baccated look, and irregu- 
larities of outline, due to displacement of their semi-fluid contents. 
If such a nerve be examined within a few days, when the 
paralysis has disappeared, the nerve tubes present but very 
slight traces of mechanical alteration, and a still later inspec- 
tion rarely shows greater alteration of the nerve, save in a very 

' Gaz. Med., 1855. » Quoted by Mitchell. Loc. cit., p. 92. 



264 Mary Putnam Jacobi 

few fibres.^ Finally, even section of a nerve acts otherwise 
than by merely separating the nerve tubes from the nerve 
centres, for it is well known that the structure of the tubes 
begins to alter in a few days after such an operation, and that 
the myeline segments and finally disappears before the nerve 
atrophies. The morbid process therefore is identical with that 
in the other cases, and it may be therefore positively asserted 
that there is no abolition of the conducting power of a nerve, 
without disturbance of its myeline. 

The rapidity with which a nerve recovers from paralysis 
caused by compression or contusion far exceeds the rapidity of 
recovery in infantile paralysis, except in such cases as those of 
Kennedy's which are by no means the most common. If, therefore, 
a mechanical lesion exist when paralysis disappears in a few 
days, much more should it be present, if due to peripheric 
interruption of nerve function, when the paralysis has lasted 
for months or years. A "peripheric" paralysis is therefore just 
the reverse of an "essential" paralysis. 

The effects of compression and contusion differ from the 
phenomena of infantile paralysis in that they are gradually in- 
duced, the paralysis is preceded by paresis, and by modifica- 
tions of the sensibility, both absent in the disease under consid- 
eration. In infantile paralysis the loss of motility resembles 
that due to only one peripheric lesion, namely, section of the 
nerve. This is especially true in the absolutely sudden cases. 
The abolition of faradaic contractility and the rapidity of muscu- 
lar atrophy are also striking points of resemblance. It is evident, 
however, that the first effect of section is not upon the nerve in 
itself, but only upon the relations between it and its centre, 
and the structural alterations of the nerve that follow are not 
apparent until from four to six days later. ^ A sudden arrest in 
the generation of motor force at the centre would be manifested 
in precisely the same way as a sudden interruption in the line 
of conveyance of such force, and indeed in no other way; just 
as there is but one phenomenon to indicate the cessation of 
chemical action in a battery where electricity is evolved, and 
interruption of the current from section of the wire by which 

' Loc. cit., p. 93. 

» Mitchell, loc. cit., p. 75. Lavuran, Thhse de Strasbourg, 1864 (quoted by 
Mitchell). Vulpian, Arch, de Phys., 1869. 



Pathogeny of Infantile Paralysis 265 

it is conducted, namely, absence of action. On the other hand, 
section of the nerve and section of the spinal cord at the point 
where it is given off, are followed by identical lesions of the 
nerve tubes, namely, loss of transparency, segmentation of mye- 
line, irregular contour of tube wall, disappearance of tube con- 
tents, proliferation of inter-tubular connective tissue, ultimate 
atrophy. There is no evidence, therefore, that an alteration in 
the functions, i.e., of the conducting power, of nerve fibres ever 
exists apart from some material alteration in their structure, and 
no suddenly produced material alteration can be even suspected 
in the type cases of infantile paralysis. 

There remains, as the conceivable seat of the so-called "essen- 
tial" paralysis, one of two alternatives — a functional alteration 
of the ultimate nervous fibrillas, at the point where they enter into 
intimate combination with muscular fibre, or a similar alteration 
at the other extremity of the nerve, where the axis-cylinders, 
from its spinal root, form the anterior nervous reticulum of the 
cord, and continue with the prolongations from the motor cells. ^ 
The possibility of a localized paralysis of the nerve-muscle 
element was first suggested by the now familiar phenomena 
of poisoning with woorara. The peripheric action of this drug 
was demonstrated by its effect upon nerves isolated from their 
centres, and its failure to paralyze others isolated from the vas- 
cular system through which the poison was circulating. A 
paral^^sis of this nature has, therefore, always been associated 
with a morbid alteration of the blood. To such alteration, and 
the demonstrable structural lesions of muscular fibre, may be 
probably attributed diphtheritic paralyses, and others observed 
during convalescence from various fevers, so well described by 
Gubler; and many cases of so-called infantile paralysis, devel- 
oped in such connections, are undoubtedly of this kind. But 
no such blood-poisoning can be suspected in the type cases of 
infantile paralysis, nor in its absence can any alteration of the 
ultimate nerve fibrillae be supposed. There remain, therefore, 
the spinal motor cells as the only possible seat of functional 
alteration, which indeed is more conceivable of elements whose 
functions are so delicate and complicated. Whether infantile 
paralysis be essential or not, it certainly must be central in its 
origin. It is the first, or negative class of autopsies, four in 

^ Boll. Archiv ftir Psychiatrie, 1873. 



266 Mary Putnam Jacobi 

number, which seem to support the idea that the central altera- 
tional is functional. The only alternative is between an annihila- 
tion of function in the motor cells of the cord preceding or in- 
dependent of any appreciable alteration of their structure, and 
a similar arrest of function, as a consequence of structural 
lesion. All truly negative autopsies, of which there are in 
reality only four, speak in favor of the first hypothesis. It re- 
mains to be seen how far or in what way the results of other 
autopsies speak in favor of the second, or how the two classes 
of facts can be reconciled. 

The theory of spinal congestion has been based, first, upon 
the same clinical facts invoked in support of the "essential" 
theory; second, upon others — such as the frequent appearance of 
the paralysis in the morning, its original generalization followed 
by limitation, the absence of rachialgic or of peripheric pains, 
the gradual improvement, or even cure; third, finally, partly 
upon the purely negative autopsies, partly upon the one recorded 
by Fleiss. It is noticeable that this latter was not in reality 
an example of congestion of the cord, but of the spinal meninges, 
and was accompanied by congestion of the cerebral meninges, 
justly ascribed to the accident that had caused the death. As 
regards the clinical history of spinal congestion, it differs from 
that of infantile paralysis — first, by the absence of important 
phenomena, characteristic of infantile paralysis, as the aboli- 
tion of faradaic contractility and the rapid muscular atrophy; 
second, by the presence of others not seen in the latter 
disease, as the invariably paraplegic form of the paralysis, the 
various modifications of the sensibility, as tingling, aching, 
burning, muscular fatigue; finally, by the frequency of pare- 
sis, which never precedes infantile paralysis, whatever the dura- 
tion of constitutional symptoms. There are certain cases, 
however, whose history does remarkably correspond to that of 
spinal congestion. The case I have quoted from Dr. Jacobi is 
a type of this kind, and is distinguished by the coincidence of 
conditions indicating a congenital imperfection of blood-vessels, 
predisposing to hemorrhage; by the preservation of faradaic 
contractility, and by the cure of the paralysis under the influ- 
ence of agents calculated to diminish the circulation of the 
spinal cord. 

In ordinary cases of spinal congestion, the peculiar symp- 



Pathogeny of Infantile Paralysis 267 

toms depend on the generalization of congestion to the entire 
thickness of the cord, including its sensitive regions; and the 
absence in infantile paralysis is explained, in the theory, by a 
hypothetical limitation of congestion to the motor regions. The 
possibility of such limitation of vascular turgescence is presup- 
posed no less in the theory of hemorrhage than in that of con- 
gestion. It is necessary, therefore, as the basis of an exami- 
nation of these two theories, to consider: ist, the anatomical 
facts relating to the distribution of blood-vessels in the spinal 
cord; 2d, the pathological lesions that have been really dis- 
covered in cases of spinal congestion or extravasation; 3d, the 
clinical history of the symptoms that have been observed in 
connection with such lesions. 

In the distribution of blood-vessels to the cord, the following 
circumstances are noteworthy : 

The spinal arteries are derived from the vertebral, but rein- 
forced all during their course by anastomoses with the ascend- 
ing cervical, intercostal, lumbar, and lateral sacral arteries. 
There are two classes of veins — those which bring the blood 
from the cord and belong to the real medullary circulation, 
and those which are interposed between the dura mater and 
the walls of the bony canal, and which form the so-called verte- 
bral sinuses or intra-rachidian plexuses. These differ from 
the cerebral sinuses by their frequent anastomoses, are but 
loosely supported by the dura mater, and surrounded by a 
semi-fluid fat. The circulation in these extra-meningeal veins 
is in close dependence upon the double rhythm determined by 
the movements of circulation and respiration in the thorax, 
and liable to be affected, therefore, by lesions of the thoracic or- 
gans. These facts show a tolerably rich circulation both in the 
cord and its membranes ; but the two last alone can be supposed 
to especially favor hemorrhage and that not into the cord, but 
in or outside of the membranes, and then not as a primitive 
accident, but as a consequence upon well-defined organic disease 
elsewhere. There are two anterior spinal arteries, and only one 
posterior; and the capillary network of the gray substance is 
richest in the anterior cornua. These are the two facts that 
might seem to render vascular turgescence or rupture more 
probable into the anterior than into the posterior segment of the 
cord. 



268 Mary Putnam Jacobi 

Finally, the anastomoses formed between the spinal arteries 
and veins, and those which reinforce them, exist at the level of 
the spinal roots. In turgescence of the vascular system, there- 
fore, pressure would be especially felt at this point, and might, 
if sufficiently intense, be supposed to interrupt nerve currents. 

The force of the foregoing considerations is, however, much 
weakened by the following : 

The arteries and veins furnished to the dura mater from the 
vessels contained in the vertebral canal, are separated from the 
cord by expansions of the vertebral ligaments. The cord is 
thus protected during turgescence of these vessels — at least of 
:mch as are of large size. The branches that enter the cord are 
of remarkably small size as compared with those of the brain, 
and subjected to much more numerous inflections. The pia 
mater into which they plunge, and by which they are sheathed, 
is much firmer than that of the brain. According to Retzius, ' 
it consists of two layers, one lining the subarachnoid space, one 
closely applied to the cord. The subarachnoid space is large, 
and occupied by septa of connective tissue, among which cir- 
culates freely the cerebro spinal fluid, constantly tending to 
restore equilibrium of pressure upon the cord. The anastomoses 
around the nerve roots are so free and extensive that an afflux 
of blood towards the cord from without, that should remain 
limited to one or two pair of roots, is almost inconceivable. Simi- 
larly, the anterior capillary networks of the axis communicate 
freely at the periphery with posterior network, and with those 
above and below them; so that the gray substance of the cord, 
instead of being divided into distinct vascular territories, as is 
the case with the brain, contains a sort of uninterrupted vascular 
column, at any one point of which the blood is with difficulty 
obstructed. Finally, the danger of interference from action of 
the heart, is diminished by the nearness of the heart to the cord ; 
and the influence of respiration is lessened from the fact, that 
while the meningeal veins empty into the superior vena cava 
during inspiration, they are free to empty into the inferior cava 
during expiration, so that a double provision is made against 
their obstruction. This is in contrast with the provision for the 
brain, and in accordance with the greater immediate danger to 
life from extensive congestion of the spinal cord. 

' Schultze's Archiv, 1873. 



Pathogeny of Infantile Paralysis 269 

It follows, therefore, that the normal anatomy of the cord 
tends to render medullary hemorrhage extremely difficult, for 
every provision is made against such local obstructions to the 
circulation as, by increasing local vascular tension, are known 
to be the efficient cause of hemorrhage into the brain. Nor has 
yet been demonstrated in the spinal arteries, the lesions, athero- 
ma, embolism, thrombosis, which are so common in the cerebral. 
Liouville alone, in a single case, was believed to have discovered 
miliary aneurisms. ^ But none of these lesions exist in children, 
or would be suspected in cases of infantile paralysis. 

A general venous congestion of the cord is from the anatomy 
conceivable, and from clinical facts demonstrable; but such 
localization of the congestion as would be required to explain 
the phenomena of infantile paralysis, is as incompatible with 
the free vascular communications just described, as are the 
sj'-mptoms of spinal congestion and those of the latter disease. 
It is true that four of the autopsies besides that of Fleiss, describe 
a dilatation of blood-vessels limited to the anterior cornua of the 
cord, but this was associated with alterations in the nutrition of 
anterior cells. Local variations in cellular activity do, indeed, 
determine local variations in the circulation ; indeed the phenom- 
ena of capillary circulation are well known to depend mainly upon 
the action of cells. In such cases, it is the alteration of the cells 
which is the efficient cause of the disease, the congestion is con- 
secutive, subordinate, and as an explanation of the paralysis, 
already necessitated by the cellular affection, may be set entirely 
aside. 

These considerations are still further sustained by analysis of 
the histories of spinal hemorrhage, — reputed a primitive acci- 
dent. Hayem has analyzed lOO cases of hemorrhage into the 
cord or its membranes, and affirms that this is the entire number 
hitherto recorded in science. Of the cases of meningeal hemor- 
rhage all but five were evidently consecutive to some other lesion, 
as, rupture of a neighboring vessel, especially with an aneurism,^ 
extension of a cerebral hemorrhage, traumatism, certain diseases 
of the nervous system, as tetanus, epilepsy, chorea, inflamma- 

' Quoted by Hayem, These sur les Hemorrhagies Intra-rachidiennes, 1871. 

From this thesis much of the foregoing has been taken. 
' Laennec, Traite d'AuscuU., t. iii., 4^ edit. p. 443. 



270 Mary Putnam Jacobi 

tions; ' finally, to certain abdominal diseases, to fevers, altera- 
tions of the blood, or poisoning, especially with strychnine. 

Of the five cases of meningeal hemorrhage that seemed the 
most purely primitive, in the first (Obs. Binard^) the vessels 
ruptured under the influence of a violent effort; in the second^ 
and third'' (Ollivier and Fallot) an encephalo-rachidian conges- 
tion preceded the hemorrhage; finally, in two cases, Gintrac-' 
and Bigot, ^ the hemorrhage occurred amidst symptoms of long- 
standing, indicating a spinal pachymeningitis. 

The cases of asserted hemorrhage into the spinal cord are 
still more ambiguous. 

Two facts are common to all: ist, the clinical symptoms of 
hemorrhage are preceded by a traumatism, or by symptoms of 
a myelitis; 2d, at the autopsy the hemorrhagic clot is found 
imbedded in tissue softened to a much greater extent than could 
be explained by its pressure, or presenting at least microscopical 
evidence of a central diffused myelitis. 

As an illustration of the usual history of such cases, I will 
relate the details of one, of which I was recently enabled to 
witness the post-mortem examination. The patient, a man of 
28 years old, after exposure in a snow-storm, was attacked by a 
severe pain in the lower part of the back, that, after lasting two 
or three days, was followed by paralysis of the left leg. This, 
however, gradually disappeared, so that three months later, the 
patient considered himself well, when one day, upon entering an 
omnibus, he suddenly lost all power over his lower limbs and fell 
to the ground. He was carried home, and although incapable 
of standing or walking, was able to move the legs a little when 
lying in bed. The paralysis extended to the sphincters, and was 
accompanied by complete anaesthesia of the lower extremities. 

' Bouchut, Gaz. des Hop., 1863. 

Joffroy, Soc. de Biol., 1870. 

Thure, Arch. Gen., 1845. 

BcUingieri, Gaz. Med., 1834. 

Griesinger, Arch, der Heilkunde, 1862. 

Fuller, Lancet, 1862. 

Calmeil, Traite des Maladies de I'encephale, 1859, t. i., p. 167. 

Ollivier d' Angers, t. ii., p. 350. 

Bruggenmann, Schmidt's Jahrb., 1836. And others. 
' Quoted by Hayem. ^ Loc. cit. ■* Archives Gen., 1830. 

s Path. Int., t. vi., p. 721. ^ These de Paris. 1847. 



Pathogeny of Infantile Paralysis 271 

In an hour or two the pain in the back returned, and became so 
extremely severe that, about the second day after the fall, mor- 
phine injections were used; a few hours later the pain disap- 
peared, but the motor paralysis was so much increased that the 
patient could not stir in bed. In the course of three or four 
months motor power was sufficiently regained to allow the patient 
to creep about a little on crutches ; but he remained generally in 
bed, and eschars of the sacrum and of the ischial tuberosities 
developed in July, about six months after the fall. He sank 
gradually, and died in October of pulmonary oedema, without 
the occurrence of any sudden accidents. At the autopsy was 
found, in the upper part of the lumbar cord, a hemorrhagic clot 
that filled a cavity about an inch long, and occupying the entire 
thickness of the cord. Around it for a quarter of an inch the 
cord was softened and altered in color. 

At the earliest this hemorrhage could not have taken place 
before January, and then would have been preceded for three 
months by symptoms of myelitis. A case related by Lancereaux 
in the Soc. de Biologic for 1861, shows that hemorrhage may 
occur in the course of a myelitis without adding any new symp- 
toms to those already existing. 

In thirty cases of hematomyelie analyzed by Hayem, the 
symptoms were analogous to those of myelitis, and in all at the 
autopsy the clot was found surrounded by softening too exten- 
sive to be the mere effect of the hemorrhage. In the famous 
case described by Cruveilhier, although there was a circum- 
scribed hemorrhage and a clot that extended from the level of 
the fourth to that of the sixth cervical vertebra, blood was also 
diffused throughout the entire gray substance of the cord — a 
lesion which almost necessarily indicates a central myelitis. ^ So 
in one case related by Brown-Sequard ^ small clots were found in 
the centre of the cord, between the origin of the second and third 
dorsal nerves, and the cord itself was softened and infiltrated 
from the third cervical to the last dorsal pair. Brown-Sequard 
quotes two other cases, in neither of which the hemorrhage was 
circumscribed. In a case by Jaccoud, the hemorrhage had oc- 
curred in the lumbar region, but coincided with an enormous 
cerebral hemorrhage. In a case communicated by Liouville to 

' Anat. Path., iiie, Livraison. 

' Lectures on Central Nervous System, p. 87. 



272 Mary Putnam Jacobi 

the Soc. de Biol. (1872), two attacks of paraplegia occurred sud- 
denly at three years' interval, and death two months after the 
second attack. Several distinct hemorrhagic foci were found in 
the lumbar cord, and the small blood-vessels in the neighborhood 
presented varicosities that Liouville considered analogous to the 
miliary aneurisms he had previously described in the arterioles 
of the brain. In another case, quoted by Hayem from Massot, 
a sudden paralysis of both arms had been followed by very rapid 
atrophy of their muscles, and also of those of the neck, thorax, 
and, to a less extent, of the lower limbs. Faradaic contractility 
was entirely lost. Death occurred suddenly, and at the autopsy 
a small hemorrhagic clot was found in the central gray sub- 
stance and posterior horns of the inferior cervical cord. But 
a reddish color extended over the greater part of this gray sub- 
stance, although the blood itself was not infiltrated. It is to the 
alteration indicated by this color, that must be attributed the 
previous paralysis and muscular atrophy, while the hemorrhage, 
which must have immediately preceded the death, was secondary 
to this. 

It sometimes happens that the symptoms of an acute myelitis, 
uncomplicated with hemorrhage, exactly resemble the accidents 
usually attributed to hemorrhage itself. This is well shown by 
a case of Roster's, recorded in Canstatt's Jahrbuch for 1870. 
A man, hitherto healthy, found himself one morning, on awaken- 
ing from sleep, to be completely paralyzed and anaesthetic in 
the lower extremities. No previous symptoms had occurred, 
except a little tingling in these same limbs during a few days. 
There was no pain, but soon dyspnoea, and then an eschar de- 
veloped, which caused death by septicemia in two months. At 
the autopsy the lumbar cord was found softened and atrophied, 
as were also the anterior roots, but there was no trace of hem- 
orrhage. Other similar cases might be quoted. Since, there- 
fore, the symptoms ascribed to hemorrhage may be identical 
with those due to myelitis, — since in cases where hemorrhage 
has really occurred, it has been preceded by symptoms of myeli- 
tis, — since, finally, at the autopsy, the hemorrhagic clot is found 
embedded in tissues softened and altered in a way to present 
all the characters of myelitis, — we are justified, we think, in 
admitting with Hayem, Dujardin, Beaumetz, Charcot, Hallo- 
peau, and Koster, that a primitive hematomj^elie is among the 



Pathogeny of Infantile Paralysis 273 

rarest of pathological accidents, and that hemorrhage hardly 
ever occurs into the spinal cord, unless its tissues have been 
previously altered by inflammation. This corroborates the in- 
ferences already drawn from the normal anatomy of the cord, 
that hardly any condition of hemorrhage can be found to exist 
in the distribution of the blood-vessels themselves. There is, 
therefore, the strongest presumptive evidence against the idea, 
that such a rare accident is the cause of so common a disease 
as infantile paralysis. Nor do the symptoms of such accident, 
when occurring, in the least degree resemble those of this dis- 
ease. They are hyperaesthesia or anaesthesia, as sudden and com- 
plete as the motor paralysis, — exaggerated reflex actions, tetanic 
contractions, where the hemorrhage is meningeal — rachialgia 
and peripheric pains, paralysis of the sphincters, production of 
eschars, march rapidly progressive, and towards a speedily fatal 
termination. It is true that, as in the theory of congestion, 
these symptoms would depend upon the extension of the lesion 
to other than the anterior regions of the spinal cord; and the 
theory of hemorrhage in infantile paralysis supposes, as in the 
case of congestion, a localization of the morbid process to the 
anterior cornua or columns. But for the same reasons as in 
this first case, such localization is only conceivable as a capillary 
phenomenon dependent on the morbid nutrition of cells, to 
which, therefore, it would be quite secondary. Still less do any 
autopsies exist to prove its possibility. Three only have been 
even quoted in connection with infantile paralysis. Of these, 
the first, Clifford Albutt's, was followed by the death of the 
child within a few hours, and the hemorrhage extended rather 
into the posterior than anterior horns. It was never even sup- 
posed to be a case of infantile paralysis, but is related by Albutt 
as an example of the way in which such disease might be pro- 
duced, had the hemorrhage taken place into the lumbar instead 
of cervical cord, where it so soon proved fatal. In the second 
case, Hayem's, paralysis had indeed occurred at two years, 
and the autopsy was made long after; but then the blood was 
found to have been infiltrated through the gray substance, as in 
cases of central, though here localized, myelitis. Finally, in 
Hammond's case a clot is said to have been found in the an- 
terior column, but the examination of the cord was insufficient 
to decide on the coexistence of inflammatory lesions. 



274 Mary Putnam Jacobi 

Among all the questions relating to infantile paralysis, the 
theory of spinal hemorrhage is the one that would seem to be 
most susceptible of elucidation by experiment. Vulpian," in 
1861, injected lycopodium powder into the anterior crural ar- 
teries of a dog, and, in several cases, found the vertebral and 
spinal arteries obliterated, and real softening with hemorrhage 
produced in the corresponding portion of the cord. These experi- 
ments should be repeated; they show how hemorrhage might 
be produced, but as they connect it with an increase of local 
arterial tension caused by circumstances that are not imitated 
pathologically, they do not really throw much light on the ques- 
tion which immediately occupies us. From review of the pre- 
ceding considerations, therefore, we must exclude the hypothesis 
of congestion or hemorrhage from the pathogeny of the great 
majority of cases of infantile paralysis. But in the cases of 
which we have made a class apart, as characterized by the 
presence of peculiar symptoms, these very lesions may very 
probably exist. 

These exceptional symptoms were complete though tempo- 
rary anaesthesia, hyperaesthesia, retention of urine, and, in one 
case, opisthotonos, all indicative of more extensive affection of 
the central axis of the cord than can be possible in cases of purely 
motor paralysis. They are, in fact, the symptoms of acute but 
circumscribed myelitis, involving the whole axis of the cord, 
and possibly, therefore, complicated with minute hemorrhages. 
All the cases of spinal paralysis occurring in the adult, even 
when resembling infantile paralysis in every other particular, 
have differed by the presence of more or less pain; also a proof 
of the wider though temporary generalization of the morbid 
process. 

The variations in the amount of constitutional disturbance, 
at the period of invasion, imply further variations in the ex- 
tension of the morbid process, even when limited to the motor 
elements of the cord. The autopsy made by Prevost, as also 
those by Roger and Damaschino, shows that altered cells and 
blood-vessels may be found scattered through a great extent of 
the gray substance of the cord, amidst elements perfectly healthy, 
and far removed from the foci of paralysis. These alterations 
indicate an original generalization of the affection, from which 

■ Gaz. Hebd., 1861. 



Pathogeny of Infantile Paralysis 275 

the majority of the elements subsequently recovered, with con- 
sequent limitation of the paralysis. Constitutional disturbance 
was in proportion to the number of elements affected at the 
moment of invasion, not to those remaining permanently injured. 
From the fact observed by Duchenne fils, that fever was less in 
proportion as the child was younger, it should be inferred that, 
at an early age, morbid communications between the cells of nerve 
centres are less facile than at a later period, when they have 
become habituated to coordinated physiological action. Com- 
munications between cells must depend on different conditions 
than those which regulate communications between nerve cells 
and nerve fibres. The originally peripheric development of the 
nervous system, and the incomplete elaboration of the cellular 
masses of the nerve centres at birth, would explain why the 
former mode of transmission should be so ready, the latter so 
much less frequent; explain the tendency, on the one hand, to 
reflex irritations, and on the other, to minute localization in the 
spinal paralysis of children. 

It has been demonstrated by Gerlach, and quite recently by 
Boll, that the prolongations of motor cells may be traced into 
direct communication with the axis cylinders of the nervous 
reticulum from which spring the anterior roots, while between 
the posterior cells and roots the communication is only inter- 
mediate. This fact may explain why, for a long time, morbid 
processes are communicated to nerves from the anterior more 
readily than from the posterior nerve cells; or, in other words, 
why in the child paralysis is more readily produced than pain. 

We speak thus confidently of motor cells, because by exclu- 
sion we have been already left to localize in them the morbid 
process, functional or organic, that is the immediate cause of 
infantile paralysis. The considerations in regard to congestion 
and hemorrhage should have served to show that the morbid 
process was at least not dependent upon them, or consecutive to 
any vascular lesion. It only remains, by reference to those au- 
topsies which have revealed some lesion of nervous elements in 
the cord, to ascertain, if possible, which among them may be 
considered primitive, and if it be the motor cells, to what known 
lesion or functional alteration the loss of their properties may 
be due. 

Four different cases exist, alike in but one point — the coinci- 



276 Mary Putnam Jacobi 

dence of muscular atrophy. In the first, the motor nerves alone 
(cases of Elischer) or of the nerves and a corresponding portion 
of the spinal cord also, were simply atrophied (cases of Hutin 
and Longet). In the second, the anterior columns and roots 
were sclerosed, without other lesion (cases of Laborde), or to- 
gether with atrophy of the nerve (case of Cornil). In the third, 
the motor cells are pigmented, as in Gombault's case of adult 
paralysis, or atrophy, and disappear. Such atrophy, with sclero- 
sis of the cornua without sclerosis of the columns, was present 
in six autopsies. Finally, in the fourth case, complex lesions 
are present, atrophy of the cells, dilatation of blood-vessels, 
fatty degeneration of their walls, fasciculated sclerosis, atrophy 
of nerves. Of these lesions, the atrophy of muscular fibre may be 
caused by any irritation of its motor nerve. When Erb crushed 
the nerve of a frog by a ligature, the nuclei of the muscular 
sarcolemmae began to multiply in two weeks, and the fibre to 
waste while retaining its striations, its place being supplied by 
hyperplasia of connective tissue. And muscular atrophy is 
known to be a common consequence of traumatic lesions of 
nerves. 

But in infantile paralysis the nerve has suffered no trauma- 
tism, yet, when examined, was usually found to have itself 
atrophied. Such atrophy can only result from a successive 
series of structural alterations, similar to those which invariably 
follow upon section of a nerve. It has been shown that the 
phenomena resulting from section of a nerve, especially the 
rapid abolition of faradaic contractility, can only be imitated 
by an abolition of the properties of the motor cells at its central 
end, and that when in these circumstances no condition existed 
capable of interrupting the conducting power of the nerve, it 
must be presumed that motor force had ceased to be generated. 
The nerve atrophy must therefore depend upon some affection 
of the motor cells, that must have persisted long enough to pro- 
duce it ; and the rapid muscular atrophy indicates that the nerve, 
either before wasting or during the process of wasting, had been 
irritated. As no cause for such irritation exists in the track of the 
nerve, it must be looked for in the motor cells; and hence these, 
either before or during the process that resulted in their abolition 
of function, must have been the seat of a peculiar irritation. 

But irritated cells are in a condition of exaggerated nutri- 



Pathogeny of Infantile Paralysis 277 

tive activity, that determines to them a local afflux of blood, and 
we have already seen that in the spinal cord no other cause for 
such minutely localized congestions could be assigned, except 
excited cellular activity. To this, therefore, must be attributed 
the dilatations and varicosities of the blood-vessels. The fat 
granules in their lymphatic sheaths result from metamorphosis 
of nutritive material, no longer needed by atrophied cells. 
Finally, while atrophy of nerve roots is associated with atrophy 
of nerves, and may be considered as an effect of this, or as a 
coincident lesion, due to the same cause; atrophy and fascicu- 
lated sclerosis of the columns of the cord, are invariably asso- 
ciated with irritative processes in the cells of the corresponding 
cornua, posterior sclerosis in tabes dorsalis, anterior sclerosis 
in myelitis, in such cases of wasting palsy as are associated with 
central lesion, and in many of the cases of infantile paralysis 
where lesions of the anterior cells were demonstrable. It is to 
be inferred, therefore, that it depended on similar cellular irri- 
tation even in the cases where lesions of cells were no longer 
demonstrable at the autopsy, as in the three where antero-lateral 
sclerosis was the only lesion found. 

The various alterations of tissue must, therefore, each be 
ascribed to an irritation of the anterior or motor cells of the 
cord, and by this reference to a unique morbid process these 
varieties are easily reconciled. The differences are explained 
by an arrest in the morbid process at different stages of its 
evolution. At any stage such alterations of special elements 
might be produced as would permanently oppose restoration of 
function, even though the cells failed to degenerate. Thus, if 
during their period of irritation sufficient irritation had been 
propagated to a motor nerve to initiate morbid processes result- 
ing in its atrophy, or in that of the muscular fibre, return of 
motion would be impossible, even though the cells, original 
source of the disorder, regained their functions. In the same 
way, a sclerosis that began to develop in the antero-lateral 
column while there were no motor impulses to be transmitted, 
would oppose a permanent barrier to their transmission when 
the generation of motor forces recommenced. 

Finally, in regard to autopsies so completely negative that 
even the nerves and muscles were found intact, we may say that 
none such are recorded, for in all four cases the muscle had 



278 Mary Putnam Jacobi 

atrophied, in two the alteration of nerve was also extremely 
marked; in the remaining two there is no mention of the nerve. 
Indeed, at present, the motor nerves are less frequently exam- 
ined than the cord, or at least with less care, so that lesions are 
more often overlooked. 

The lesions discovered in the motor cells, therefore, indicate 
the nature of the morbid process as decidedly in the cases where 
they are absent, as in those where they are found. Cellular 
atrophy is a proof that the molecular nutrition of the cells has 
been arrested. It is evident, however, that the abolition of 
function, so nearly sudden, must coincide with the first distur- 
bance of nutrition, and not only with its ultimate consequence, 
cell atrophy, which must be accomplished gradually. While 
it is as conceivable that the chemical metamorphoses in the cell 
may be instantly arrested by means of an impression conveyed 
to it by a nerve, as that the chemical processes going on in a 
solution of inorganic salts should be arrested by the passage of 
a current of electricity. Both cases illustrate the now familiar 
law of the correlation of forces, of the relations between chemical 
affinities and electrical or neural actions. 

The alterations of motor cells in infantile paralysis serve ^ 
therefore, as a point of transition between so-called functional 
disorders and so-called organic diseases, and show with exquisite 
precision the manner in which alterations of tissue may be de- 
termined by perversions in the nutrition of cells. 

Cases other than those of infantile paralysis are not alto- 
gether rare, where the annihilation of function in important 
nerve cells has been so complete, that death has occurred in a 
few days, and before atrophic lesions had had time to develop. 
Tetanus has long been a familiar example, and here, as in in- 
fantile paralysis, more accurate microscopical researches are 
beginning to discover lesions of the cord, when life has been 
sufficiently prolonged. Certain curious cases of acute ascend- 
ing paralysis fall under the same category. In the one related 
by Pellegrino Lewins in the Archives Generates for 1865, the 
death is probably due to annihilation of the functions of the 
brain. But another quoted in the thesis of Petit fils, where the 
autopsy was made by Comil and Ranvier, is more conclusive. 
In the midst of apparent health occurred a sudden paraplegia, 
accompanied by fall of temperature and analgesia in the affect- 



Pathogeny of Infantile Paralysis 279 

ed limbs, pain in the lumbar region of the back, abolition of 
reflex movements. Anaesthesia without paralysis extended to 
the upper extremities, and death supervened on the fifth day in 
cyanosis, from failure of the motor forces of respiration. The 
most careful examination of the brain and spinal cord could 
discover no lesion, even microscopic. 

In regard to the manner in which the nutrition of the ante- 
rior cells may be arrested, it is well known that two theories are 
in presence. According to one, a peripheric irritation causes 
a spasmodic "reflex" contraction of the blood-vessels of the 
spinal cord. According to the other, this irritation is directly 
propagated, by means of an afferent nerve, to a cell whose nutri- 
tive metamorphoses are arrested, as might be the chemical reac- 
tions in a retort by the passage of an electric current. The 
clearest expression of this theory has perhaps been given by 
Mitchell, in the paper contributed to this polemic by him,^ and 
reindorsed in his recent book, On Injuries to Nerves. " It appears 
to him possible that an injury may be competent so to exhaus^ 
the irritability of the nerve centres, as to occasion more or less 
permanent loss of function. A strong electric current is cer- 
tainly able to cause such a result in a nerve trunk; and reflect- 
ing on the close correlation of the electrical and neural force, 
it does not seem improbable that a violent excitement of a nerve 
trunk, however brought about, should be able to completely 
exhaust the power of its connected nerve centre. . . . There is 
no reason why, if shock be competent to destroy vitality in 
vaso-motor nerves or centres it should be incompetent to so 
affect the centres of motion or sensation." Handfield Jones ^ 
declares as the result of many clinical observations, "that any 
afferent nerve may act as an inhibitory nerve upon the centre 
or centres with which it is connected, disordering or paralyzing 
its action." In the first number of his Archives, Brown-Sequard 
has detailed many illustrations of such inhibitory actions, af- 
fected by the most diverse sensitive nerves on the most different 
central ganglia. Eulenburg quotes the experiment of Lewisson,'' 
who by strong irritation of the cutaneous nerves of a frog, sus- 
pended motor power, not only in the irritated limb, but in the 

' New York MedicalJournal, 1866. See also Jaccoud, Paraplegic et V Ataxic. 

' Functional Nervous Disorders, pp. 9 and 16, 1870. 

^ Lehrbuch, p. 428, quotes Archiv. Reicheri and Dh Bois-Reymond, 1869. 



28o Mary Putnam Jacobi 

others, and considers it a proof that the centripetal irritation of 
sensitive nerve is sufficient to arrest the functions of the nerve 
centres. The anatomical facts of infantile paralysis show- 
finally that the function of such centres is arrested by inter- 
ference with the chemical processes in the nutrition of the nerve 
cells. 

The immense pathological importance of the study of infan- 
tile paralysis may be best appreciated by enumerating its dif- 
ferent pathological relations, which the foregoing pages have 
tried to set in relief. 

I St. It links together tne most conspicuous external deformi- 
ties, involving entire limbs, with lesions of internal microscopic 
groups of cells, so minute as, until recently, to have escaped 
observation. 

2d. By exquisite localization of pathological lesions it con- 
firms the doctrine of localization of function and independence 
of morbid processes in special groups of nerve cells. 

3d. It helps to establish a group of diseases bearing various 
relations of cause or effect to this same group of cells — the 
anterior spinal — as adult spinal paralysis, progressive muscular 
atrophy; finally, even bulbar paralysis, where the disease is 
confined to the groups of motor cells in the medulla. 

4th. With these others it helps to show the immense and 
peculiar influence exercised upon the nutrition of muscles by 
the nerve cells influencing their motor nerves. This influence 
is in both resemblance and contrast with that exercised on the 
nutrition of the skin and subcutaneous tissues by the groups 
of cells connected with the posterior roots and sensitive nerves. 
Lesions of these produce eschars, as of those, atrophy, sclerosis, 
or fatty degeneration. 

5th. As a localized myelitis, certain cases, at least, of in- 
fantile paralysis are to be considered in their relations to other 
forms of myelitis, localized or diffused, parenchymatous or 
interstitial. They are to be contrasted with cases of tabes dor- 
salis, in which the myelitis localized in the posterior comua 
determines a fasciculated sclerosis of the posterior columns, rela- 
tively more frequent and important than the anterior sclerosis, 
contrasted also with the anterior lesion of wasting palsy, which, 
from the slow march of the disease, may often depend on an 
extension of irritation from the periphery; contrasted with acute 



Pathogeny of Infantile Paralysis 281 

diffused central myelitis, with equally rapid march, but where 
the lesion involves both neuroglia and nervous elements. 

6th. As originally confined to the latter, the lesions of infan- 
tile paralysis offer one of the best illustrations of the "parenchy- 
matous inflammation," long ago described by Virchow. 

yth. By its sudden invasion infantile paralysis is symptoma- 
tically allied to such accidents of the vascular system as conges- 
tion or hemorrhage. But as these are shown to be either ab- 
sent or rare, or consecutive to an affection of nerve cells, the 
capacity for independent morbid action possessed by these latter 
receives another confirmation. 

8th. These affections serve as a link between the so-called 
reflex or inhibitory paralysis and those dependent on marked 
lesions of the cord. 

9th. Finally, they trace minutely the successive steps in a 
morbid process that, beginning in a functional alteration of 
cellular nutrition, terminates in organic destruction of tissue, 
and thus dissect apart the complex phenomena both of inflam- 
mation and of general cell life. 

APPENDIX 

To the cases described in the preceding pages, I am enabled 
to add another, observed since the reading of the paper. 

On the 1 8th of February a paralyzed child died at Dr. 
Knight's hospital, whose history was as follows. When a year 
old, the boy had had an attack of dysentery, and on recovery 
was found to be paralyzed in all the four limbs, and even in the 
muscles of the neck and back. These regained their power 
first, so that after a few weeks, the child was able to sit; then 
recovered the use of his arms, but the paralysis persisted in the 
lower extremities, being most marked on the left side below the 
knee. Admission to the hospital eight years later with para- 
plegia and atrophy of the paralyzed limbs. There was then 
not the slightest reaction to galvanic or faradaic electricity on 
the left side, but some response to the induced current was ob- 
tained on the right. The general health of the patient was ex- 
cellent, and remained so to the day of his death. On the morn- 
ing of that day he arose at 5}/^, still apparently well; at 63^ 
vomited, and was found sitting down in a corner of the ward, 
complaining of feeling ill. While the attendant was questioning 



282 Mary Putnam Jacobi 

him, he suddenly turned pale, fell forward on the floor, became 
almost instantly pulseless, and in five minutes was dead. 

The autopsy was made by Dr. Janeway in the presence of 
Drs. Knight, Gibney, Milner and myself. The paralyzed limbs, 
spinal cord, and brain were all examined with care. The muscles 
of the left leg were almost entirely converted into fat. The 
right gastrocnemius was equally fatty, but the deep muscular 
layer was tolerably preserved. To this fact was due the degree 
of electrical reaction that had been observed during life, as also 
a certain amount of voluntary control of the limb. 

The cervical region of the cord was somewhat injected, and 
a little blood was infiltrated between the dura mater and the 
arachnoid. This came from the cranium. In this same region, 
careful inspection showed that the antero-lateral column was 
somewhat diminished in size on the right side. In the lumbar 
region, on the contrary, the atrophy existed on the left side, and 
by the aid of a magnifying glass was seen to extend to the left 
horn of gray matter. 

It has not yet been possible to make the microscopical ex- 
amination, but its results will be published as soon as obtained. 

The cause of death was found in the brain. A hemorrhage 
had taken place into the left posterior lobe of the cerebellum. 
About an ounce of blood was contained in a cavity the size of a 
walnut. Blood had fused along the base of the brain to the 
anterior fossae, and also, as before observed, had descended into 
the spinal membranes. The entire brain, and especially the left 
half of the cerebellum, was much injected. 

The first symptoms presented by the child evidently coin- 
cided with the commencement of the hemorrhage, and when the 
effused blood became sufficient in quantity to press upon the 
medulla (with which, at the autopsy, the outer edge of the clot 
was found almost in contact), death occurred, with the choc en 
avant, so characteristic of sudden lesions of the medulla or cervical 
cord. Examination (by Dr. Janeway) of the blood-vessels of 
the cerebellimi, found them extremely fatty. 

Fatty degeneration of the encephalic blood-vessels, and hem- 
orrhage into the cerebellum, are lesions so rare in a child of nine 
years old, as already to render this autopsy of especial interest. 
But more important for our present purpose, is the examination 
of the cord in a case of paralysis dating from infancy, and that. 



Pathogeny of Infantile Paralysis 283 

even before the mcroscopical examination, can already be said 
to show the lesions now to be considered as characteristic, namely, 
atrophy of the antero-lateral columns, and of the anterior cornua. 
Nevertheless, we doubt that this case can be claimed as a type 
of Infantile Paralysis. A general paralysis after a febrile disease, 
as dysentery, may, with at least as much probability, be attribut- 
ed to primitive degenerations of the muscles, to which the 
atrophy of the motor elements of the cord was only secondary. 



REMARKS UPON THE ACTION OF NITRATE OF SILVER 
ON EPITHELIAL AND GLAND CELLS.' 

READ AT THE MEETING OF THE NEW YORK STATE MEDICAL 
SOCIETY, 1874. 

Mr. President: When I learned that I was to have the 
honor of being present at this meeting of the Association, I hoped 
to be able to submit to it and to you the results of some extensive 
experiments upon the topical action of medicines. These experi- 
ments I have indeed begun, but have been unavoidably hindered 
in carrying them far enough to arrive at many satisfactory re- 
sults. Instead, therefore, of a memoir worthy of your attention, 
I am able only to offer a brief note upon a few details that, how- 
ever, I trust are not devoid of interest. 

The importance of topical medicine will always vary, in 
public esteem, according to the stress that is laid upon local 
diseases. There have been many periods, in the history of 
medicine, when the attention of physicians was so much absorbed 
by the general forces of the economy, that local diseases, or local 
manifestations of constitutional disease, were neglected. It was 
assimied, or rather it has been asstuned more than once, that if 
the unknown vital forces were restrained, or sustained, or 
encouraged, or depressed, or stimulated, or purified, that visible 
lesions would disappear of themselves. Even when local treat- 
ment was used, it was often only for the purpose of attacking the 
general principle at a presumably vulnerable point. Hence the 
eulogiums passed upon the value of aromatics and balsams in the 
treatment of wounds. These famous remedies were designed 
not to heal the wound directly, but to revive the vital spirits 

2 Reprinted from the Transactions of the New York Staie Medical Society, 
1874- 

284 



Action of Nitrate of Silver 285 

fainting because of it. To-day, aromatics are replaced, by dis- 
infectants, or only retained in virtue of a disinfectant property 
which they may perchance possess. The wound is regarded, not 
merely as the gaping door through which the soul may be 
breathed forth towards Hades, but as an active focus of infection, 
from which may flow inwards a constantly rising stream of 
poison. The efforts of modern medicine are directed, wherever 
possible, less to the sustenance of vital force than to the destruc- 
tion of the agents by which such force may be destroyed. In the 
history of an immense number of diseases, therefore, the atten- 
tion of the physician is to-day, and most profitably, directed to 
one of two points: ist, the existence of a focus of infection; 2nd, 
the existence of a drain. To the destruction of the one, or the 
closure of the other he bends his most powerful energies. I need 
scarcely recall the specific cases that illustrate most strikingly this 
present attitude : that surgical and puerperal fever are regarded 
as the results of local auto-infection; that the dangers of osteo- 
myelitis are known to be those of pyaemia; that to the reabsorp- 
tion of pus is attributed the principal danger in small-pox; that 
even tuberculosis has been traced to a local origin in cheesy 
deposits, sometimes unique. On the other hand, the importance 
of chronic inflammations and suppurations as permanent drains 
upon the system, can only be adequately appreciated when as 
has been done, the exuded material has been analyzed, and its 
composition compared with that of the blood and tissues whose 
nutrition it exhausts It is in this way that a chronic bronchial, 
intestinal, or uterine catarrh may be justly compared in its 
effects to a chronic albtuninuria. 

Catarrhal inflammations are among the most frequent of all 
diseases, and interest the localist because of the definite changes 
in anatomical tissues they offer to his observation; and interest 
the constitutionalist by reacting upon the general system in three 
ways. They are a door of drainage, a point of irritation, and, 
when acute, are frequently also a focus of auto-infection. To- 
day nearly all of this class of diseases are treated by topical 
medication, and this is intended, or desired, even when its 
application has not yet been rendered possible. 

It is evident that every substance directly applied to a tissue, 
in order to modify the nutrition of that tissue, can only be handled 
to complete advantage when its precise action upon each of the 



2 86 Mary Putnam Jacobi 

elements has been demonstrated. A complete demonstration — 
chemical, physiological, and morphological — is very far from 
being at present in our grasp for the majority of tissues or medi- 
cines. But the morphological changes, or the alterations of form, 
in the elements, submitted to the influence of the drug, are, in 
many cases, easy to observe under the microscope. 

Of all elements whose reaction to topical medicines is interest- 
ing to us, that of the various epitheliums is most intensely so. 
"All the surfaces of the body which are in contact with the 
external medium, as the skin, respiratory passages, digestive 
tube; all which inclose blood or lymph; all the walls of closed 
cavities, serous, glandular, sensorial, are, with rare exceptions, 
lined by the cells variously known as epidermic, endothelial, 
epithelial — the latter spherical — cylindrical, pavement, as the 
case may be."^ Everjrthing that passes into the blood, and 
everything that passes out, must traverse one or more layers of 
epithelium. Upon its integrity, therefore, depends the nutrition 
of the entire body. No mucous and no serous membrane can 
become inflamed without involving at the outset this almost 
ubiquitous tissue. A large nimiber of skin diseases depend in the 
morbid changes to which it is liable. It prevents or facilitates 
the absorption of many miasms or specific poisons, and its morbid 
reactions furnish the most delicate tests for their elimination. 
The characteristic products of many diseases are principally 
masses of degenerate epithelium; thus the exudation that blocks 
the alveoli in many forms of pnetunonia, the casts of nephritis, 
the dejections of cholera. Nor is the interest of epithelium 
diminished when we examine its history, and the part it plays in 
the normal or pathological genesis of tissues, since Waldeyer has 
traced the ovule to an epithelial cell, and Thiersch believes to 
have demonstrated the origin of cancer in epithelial tissue. 

Among topical medicines most frequently used, there is one 
that, in researches remote from therapeutics, has been shown to 
exercise a special action upon epithelial cells. I allude to nitrate 
of silver. In therapeutics this drug is used to meet three classes 
of indications: to modify inflamed mucous membranes; to des- 
troy morbid tissue; finally, after absorption, to arrest functional 
or organic diseases of the nervous system. This last indication is 
also among the most ancient discovered ; for, as Charcot and Ball 

■ Farabeuf. De VEpiderme et des Epitheliums. 1872. 



Action of Nitrate of Silver 287 

remark, "the use of nitrate of silver was only generalized after 
the promulgation of the theory of microcosm and macrocosm, in 
which every terrestrial metal was made to correspond, on the one 
hand, to a celestial body, on the other, to some organ of the 
human frame. It was on account of the mysterious trinity 
which united silver to the moon, and the moon to diseases of the 
brain, that salts of silver were used in the treatment of nervous 
affections."* 

The practice continues in modern times, but is to be justified, 
if at all, upon far other grounds. Ranvier has treated nerves 
with a solution of nitrate of silver, containing i part of the salt 
to 300 of distilled water. This was poured upon the nerve 
before removing the latter from the body. In a few minutes 
the nerve, which was translucid and elastic, became opaque and 
rigid. It was washed and examined in glycerine. At a low 
magnifying power could be distinguished, ist, the sheath of 
connective tissue, lined with large pavement epithelium; 2d, a 
number of little black crosses, studding the surface of the nerve. 
With a magnifying power of 600, the vertical branch of each cross 
was found to consist of the cylinder axis of a nerve fibre, black- 
ened to the extent of the figure, by a deposit of silver; and the 
transverse branch was formed by a ring of silver deposit, sur- 
rounding the nerve fibre, and partly strangulating it. Although 
not yet demonstrated, the dilution of the agent used to deter- 
mine this effect, renders the topical application in some degree 
comparable with internal administration, when the silver brought 
to the nerve tissue shall have been diluted by the whole mass of 
the blood. 

The action of nitrate of silver upon mucous membranes is gen- 
erally and curtly described as "astringent," and due to its prop- 
erty of coagulating albimien. The caustic action, admitted to be 
very superficial, is interpreted as an exaggeration of this astrin- 
gency. Not only the albumen of surface secretions, but the 
albimiinous constituents of tissues, it is said to be coagulated; 
their vitality is arrested and an eschar formed. As a catheretic, 
nitrate of silver is particularly praised on account of the precise 
limitation of its action, and because the dense coagulum it forms 
seems to constitute an effectual barrier to its reabsorption. Now 
we shall have occasion to show that a strong non-caustic solution 

» Diction. EncycL, vol. vi., p. 63. 



288 Mary Putnam Jacobi 

of nitrate of silver may form precisely such a barrier, while on 
the other hand, the phenomena of reaction that occur beneath 
and around the eschar really extend its influence to a considerable 
distance. Few microscopic researches have been made on this 
subject as yet, but two series of experiments have fallen under my 
notice, whose bearing on this point is important. The first 
experiments to which I allude are by Alexander Stuart, and are 
described in the first volume of Schultze's Archives. Stuart 
cauterized the thigh muscles of a living frog with nitrate of 
silver to the extent of half a square centimetre in width, and one 
centimetre in depth. Two classes of alterations were seen, 
those representing the pure chemical action of the caustic, and 
others, the result of the secondary inflammation. At the point of 
cauterization the muscles assumed a diaphanous white color, and 
the muscular fibres degenerated to a granular or finely fibrillar 
mass, distending the sarcolemma. This mass presented all the 
chemical characters of coagulated albtmien. 

The non-cauterized muscular fibres exhibited various changes, 
progressing towards the final conversion of their protein sub- 
stance into fat. The transverse stratum appeared white and 
faint, the color was transparent and whitish, sometimes opal- 
escent. Chemical alterations (which I will not stop to detail) 
preceded definite changes in form. Later, granules appeared, 
destined to become fat; the sarcolemma thickened, the nuclei 
increased in size, and ultimately proliferated. These changes 
were accomplished in from two or three weeks. The fibres 
became completely fatty in from two to three months. 

The other experiments to which I have referred are those, so 
famous, of Cohnheim, who applied nitrate of silver to the tongue 
of the living frog. His observation was directed principally to 
the changes in the blood vessels. His observations are so widely 
known that I will only briefly recall them. In the zone immedi- 
ately surrounding the eschar, the arteries leading to it rapidly 
dilated; then the veins and capillaries. The circulation at the 
same time is accelerated. Then the vessels feel the effect oi the 
obstacle offered to the circulation by the eschar, and in those lead- 
ing directly to it ; the circulation slackens, and finally stagnates as 
far as the nearest collaterals, and in these the acceleration of cir- 
culation continues. These alterations are purely mechanical. 
In an hour or two after the application of the cautery the dilated 



Action of Nitrate of Silver 289 

arteries most remote from the eschar begin to contract, and the 
calibre as well as rate of circulation is restored everywhere except 
at the point of cauterization, and two zones surrounding it. In 
the inner of these two is complete stagnation; in the other, 
persistent dilatation of all blood vessels; after six and eight 
hours begins the diapedesis of white and red blood corpuscles. 

Cohnheim observes that other caustics, as potassa, or nitrate 
of mercury, act in the same way, while mechanical irritation, 
unless long continued, produces a far inferior effect. The 
chemical action of the caustic was more powerful in affecting 
the coasts of blood vessels. These experiments are quoted 
merely to show with what limitations we may accept the dictum 
that the effects of lunar caustic are precisely confined to the point 
at which it is applied. Therapeutically, such microscopic observa- 
tions are of value, when we are called upon to judge such 
propositions as that of leaving a piece of solid nitrate of silver 
to melt in the cavity of the uterus. It is certain that the action 
immediately produced by lunar caustic only represents a portion 
of its action; the secondary effects on surrounding tissue are more 
important, sometimes more beneficial, often more dangerous. 
Among all the mucous membranes that have been treated in all 
variety of ways with nitrate of silver, that of the neck and body 
of the uterus is certainly the most often in cause. The cauteri- 
zation of the pharynx and larynx with concentrated solutions, 
or with saturated spray, are equally familiar applications; the 
alleged introduction of nitrate of silver into the bronchial tubes by 
means of the probang, is one of the most piquant details in the 
history of the nitrate, perhaps in the history of contemporary 
medicine. But it is not my object to enumerate the various 
indications for utilizing the action of nitrate of silver upon 
mucous membranes. I wish merely to compare certain details 
of this treatment with details in the microscopic preparation of 
the same tissues. It is well known that when fresh membranes, 
covered with epithelial or endothelial cells, are bathed for a few 
minutes in solutions of nitrate of silver, that these cells are 
distinctly outlined by intense black borders corresponding to 
their natural boundaries. To obtain this effect it is necessary 
to use extremely dilute solutions. Klein recommends one part 
to two hundred or four hundred of water. Robinski uses solu- 
tions of one part to five hundred, to eight hundred, or even to one 



290 Mary Putnam Jacobi 

thousand; and the latter preparations are preferred by Alferow. 
This fact is of importance for our purpose, for it renders the result 
of the direct application of silver salts to epithelium in some 
respects comparable to those that we might look for when it had 
been absorbed from the stomach, and brought to the tissues 
diluted by the whole mass of the blood. No single therapeutical 
dose, it is true, would give even this proportion;^ but it is the 
property of many mineral substances to accumulate in tissues, 
and this is well known to be pre-eminently true of silver. This 
remark by the way. By whatever mechanism the black silver 
lines may be produced, the service that their discovery has 
already rendered to histology is immense. The paths of lym- 
phatics have been traced more delicately than even by Sappey's 
injections; and if we may believe Recklinghausen, Auerbach and 
Klein, the ancient views on the structure of lymphatics have 
been revolutionized, since all are shown to possess an epithelial 
lining. Stomata 'have been discovered on serous membranes, 
analogous to those on the epidermis of plants, and leading like 
them to sub^epithelial spaces. New dangers — or rather more 
adequate explanation of old dangers — have been found in 
inflammations of these membranes, now viewed as immense 
lymph sacks; and the tendinous centre of the diaphragm has 
been invested with a special function of absorption hitherto 
unsuspected. This silver method has been used by Cohnheim 
to demonstrate the passage of red corpuscles between the endo- 
thelium of blood vessels, and by Alferow to test the passage of 
white corpuscles between the endotheliiun of the mesentery. 
We have just seen what application has been made of it 
by Ranvier. It would seem, therefore, that the new role of 
nitrate of silver in histology bids fair to rival its ancient prestige in 
therapeutics. 

We have mentioned the fact, so well known, that when very 
dilute solutions of nitrate are used, and are only in contact with 
the membrane for a few minutes, and this only exposed to the 
light for a few seconds, that the black deposit occurs only on the 
boundary lines between the cells. But with eveiy increase in 
the strength of the solution, in the prolongation of its contact, or 
of the subsequent influence of the light, the coloration extends 

'With i8 lbs., or 147,040 grains (18 X 16 X 480 = 147,040), Therap. in- 
ternal dose = i to I gr. 



Action of Nitrate of Silver 291 

toward the centre of the cell, invading the nucleus, If at all, the 
very last. Sometimes, as in the mesentery of the frog, the 
nucleus remains clear in the midst of a uniformly brown cell. 
His has said that on the cornea a weak solution of nitrate of 
silver produced a deposit within the cornean corpuscles; while 
with a strong solution these remained pale and colorless and the 
deposit was formed in the intercellular substance. Schweiggel 
Seidel attributes the lines to a precipitation of albimiinous fluid 
lying in furrows between the convex surface of the cells. Klein 
and, I believe, Recklinghausen, explain them by precipitations 
in an intercellular albuminous substance that holds together the 
individual cells. 

Robinski denies the existence of this substance, and considers 
the lines to be an optical effect due to the position of the cells. 
These are uniformly colored from the beginning, but according 
to Robinski, this coloration must appear more intense first upon 
the edges because these are seen. 

For our purpose it is essential to estimate the effects of the 
deposit, within or without the cells, upon their vitality and 
detriscence. It cannot be determined, a priori, whether the 
partial coagulation of an albimiinous intercellular substance 
should retain the cells in place, or facilitate their fall; it is certain, 
however, that the effects of the silver must be very different upon 
living membranes and those removed from the body, and also 
that it must vary extremely with the strength of the solution. 
The very weakest solution used therapeutically should, from 
what precedes, produce a deposit that should extend through and 
color the entire cell. Whatever effect on the vitality of the cell 
would be occasioned by a deposit on its edges would be compli- 
cated, therefore, by that formed in its interior. 

These considerations should suggest the necessity for an 
immense number of experiments. Of the series that I have 
sketched out for myself, I have so far only accomplished the 
following: 

1st. Treatment of fresh mucous membrane from stomach of 
recently killed rabbi' , with one-half per cent, solution of nitrate 
of silver. 

2d. Administration to rabbit of one grain nitrate in a fluid 
drachm of distilled water. 

3d. Treatment of human uvula, immediately after excision, 



292 Mary Putnam Jacobi 

with a forty-grain solution of nitrate of silver, that frequently 
employed in pharyngeal catarrh. 

4th. Application to mucous membrane of pharynx of eight 
grains solution of nitrate, and immediate excision of small pieces 
of mucous membrane so bathed. Before experimenting upon 
the complicated mucous membrane of the stomach I made a 
certain number of preparations of the normal stomach of the 
dog and rabbit. Some of these preparations I have brought with 
me. They are made according to Heidenhain's method, as 
described in his original memoir and exhibit the principal details 
which have since been accepted in the most recent text-books on 
the rabbit. A vertical section of the mucous membrane of the 
stomach was said by Heidenhain to exhibit, at a low magnifying 
power, four distinct parts. In my preparations, three of these 
are distinct. Proceeding from the internal surface, is seen, ist, a 
border, deeply colored by carmine, fringed, or irregularly sinuous 
on the free edge, with outlines of cells faintly discernible; 2d, a 
narrower space, almost colorless, and where the outline of cells 
can scarcely be discerned; 3d, the gland tubes, Ijing parallel to 
one another, separated by a little connective tissue, filled with 
much larger cells, colored principally on the two walls, and leav- 
ing the centre pale. The gland cells are much less colored by 
carmine than is the epithelium. 

In the dog, the sinuosities on the free edge are really much 
deeper, but the proportion of the red border to the rest of the 
tubes is much less than in the rabbit. 

At a higher magnifying power (200 diameters) additional 
details are perceived. First, the red border is seen to consist of 
the cylindrical epithelium lining the depressions in the mucous 
membrane, into which one or more gland tubes open. This 
epitheliiim gradually passes into round cells, and these into 
larger, more polygonal ones; the clear space below the epithelial 
border is seen to consist of the latter, intermediate between the 
round and the peptic cells. Finally, these latter, as shown by 
Heidenhain, and afterwards by Rollet, are of two kinds — border 
cells, colored by carmine, and central or principal cells, scarcely 
colored. Heidenhain shows that the latter are tumefied during 
digestion, while the former remain unchanged. This fact would 
imply that they were the seat of the peptic secretion, while the 
border cells, colored like epithelium with carmine, resemble it also 



Action of Nitrate of Silver 293 

in function, being analogous to the epithelial cells that exclusively 
occupy the non-peptic glands of the pylorus. 

In the dog I have remarked one detail, not mentioned by 
Heidenhain or Rollet. The epithelial border seemed to consist 
of two layers of cells, of which the external was deeply spiculated. 
The lower part of the cell, deeply colored, was thus surrounded 
by quite a broad, clear border. This appearance suggested an 
analogy with the spicules described by Frey on' the pavement 
epithelium of the mouth and pharynx, and that as in this locality 
the epithelium was held more firmly in place, the clear space 
below the epithelium is much less distinct in the dog; the gland 
tubes larger, and the polygonal cells larger and more distinct. 
The arrangement of the border cells is more regular. 

These points ascertained, I sacrificed a rabbit, and immedi- 
ately removing the mucous membrane of the stomach, washed it, 
and left it for a few minutes in a half per cent, solution of nitrate 
of silver. It was then exposed to the light for ten minutes, but 
became intensely colored, the coloration increasing during the 
subsequent hardening in alcohol. 

On microscopic examination of sections, uncolored by car- 
mine, a dark brown border was observed occupying precisely the 
place of the carmine coloration; that is, the whole layer of 
epithelium. In a few places could be seen that the brown deposit 
was much darker around the epithelial cells than within them, 
and filled up the whole of the open mouth of the gland. In some 
places a brown coagulum lay in the free surface of the mem- 
brane, over the epithelium, and apparently formed of coagulated 
mucus. But this was by no means constant. Any albuminate 
that had been so formed had evidently been removed by the 
washing. The facility with which this was done implies that 
the pressure of such coagulum upon the subjacent cells, could not, 
as is often asserted, exercise much influence. In the colored 
specimens the carmine covered the silvered epithelium, but was 
very much darker in tint than usual. It was evident that the 
presence of silver in the cells, demonstrated in the uncolored 
preparations, did not deprive these elements of the power of tak- 
ing up carmine. A brown border was formed around the cells, 
and in the centre of the funnel-mouths of the tubes, as before. 
The peptic cells were quite unaltered. Nevertheless, scattered 
over the surface of the tubes, appeared a number of very fine 



294 Mary Putnam Jacobi 

black granules. These were the only sign that this dilute solution 
of nitrate of silver, applicable to membranes deprived of their 
vital connections, although themselves still alive, could penetrate 
below the epithelium covering. 

A similar fact was shown by examination of the mucous mem- 
brane of the human uvula dipped in a solution of nitrate, con- 
taining forty grains to the fluid ounce, or rather more than 8 per 
cent. The surface became very brown, but not nearly as dark as 
the rabbit's stomach, and while hardening in alcohol, a large 
amount of brownish precipitate separated. The difference in 
color may have been due to the difference in epitheliimi, the 
dense, stratified epithelium of the uvula being more resistant 
than the cylindrical cells of the stomach. But besides the con- 
tact was much less prolonged. Sections showed a clear brown 
border, in which the outlines of the external layer of epithelial 
cells were distinctly marked. This border did not, however, 
extend throughout the epithelium, four or five layers of which 
remained perfectly colorless. The epithelial conjunctive tissue 
and glands were entirely unchanged. 

The mucous membrane excised, after painting with an eight- 
grain solution (about if), gave absolutely the same results, 
except that the brown border was narrower. It also, however, 
was formed by the outer layer of epithelium, and not by a layer 
of coagulated mucus. 

All the above preparations I have brought with me. 

The administration of one grain of nitrate of silver to a living 
rabbit was, however, followed by quite different results. After 
the first dose the rabbit did not appear to suffer, and the same 
was repeated eighteen hours later. Three hours afterwards the 
rabbit was found dead. This was unexpected; for although 
rabbits, as being unable to vomit, are more susceptible to the 
irritation of nitrate of silver than dogs, yet they are known to 
tolerate much larger doses than this, at least if reached gradually. 
Bogoslowsky gave a rabbit from one to ten grains daily for thirty- 
six days.' At the autopsy of the rabbit the stomach offered 
many symptoms of acute catarrh. It was not hyperaemiated, 
but slightly grayish in spots, covered with abundant flakes that 
looked like coagulated mucus, and eroded to different depths 
in various places. The stomach was washed in distilled water, 

* Archives Virchow, Bd. 46, 1869, 



Action of Nitrate of Silver 295 

the flakes placed in glycerine, the thinned mucous membrane 
hardened in alcohol, and each examined. 

The flakes so exactly resembled those mentioned in all 
descriptions of acute gastric catarrh, and summarily dismissed as 
coagulated mucus, that I had not the least expectation of finding 
anything else. Great was my astonishment to find them ex- 
clusively composed of large polygonal cells, arranged in coltmins 
two or three thick, and in many places exactly simulating the 
peptic glands, of which they were evidently the casts. The cells 
were evidently much larger than those I had previously seen on a 
rabbit, larger even than the peptic cells of the dog. The nucleus 
was also large and remarkably distinct. The cells were partly 
filled with granulated matter. So far their condition resembled 
that described by Heidenhain as characterizing the period of 
digestion. But the source of their irritation was seen in the 
grayish color that many had assumed, as if from a very minute 
deposit of silver. Many cells were perfectly clear and pale. 

To a specimen of these flakes, immersed in glycerine, a very 
minute quantity of tincture of iodine was added, scarcely suffici- 
ent to color the solution. After this addition, the cell walls 
nearly all disappeared, and instead of columns of polygonal cells, 
appeared masses of very distinct nuclei. The mucous membrane 
from which these flakes had exfoliated, was in many places 
diminished to half or a quarter its normal thickness. Empty 
spaces showed where gland cells, or gland tubes, had been. The 
epithelium was everywhere absent, but in most specimens re- 
mained a narrow, irregular border, deeply colored by carmine, 
and seeming to represent the round cells at the base of the 
epithelium. In one specimen only the highly colored nuclei of 
these cells remained, the walls seemed to have been dissolved 
away. The gland cells were all much larger than normal, the 
nuclei distinct and intensely colored by carmine, the cells in many 
places seeming to ascend from their places. On one specimen the 
lower part of some of the tubes was filled with fine detritus. 
None of the cells were, however, in the least colored, nor was there 
the least brown or gray tint over any part of the preparation. 
Whether or no the epithelium had been colored, but washed 
away, was impossible to ascertain. But as there was no epithe- 
litun in the flakes that covered the mucous membrane, it was 
hardly to be looked for underneath them. It had apparently 



296 Mary Putnam Jacob! 

been completely destroyed. This difference cannot be ascribed 
merely to the dilution of the silver salt, which was one and two- 
third per cent, (one grain to sixty grains distilled water), a good 
deal stronger, therefore, than that with which the stomach from 
the dead rabbit had been treated. Yet in this case a dense 
brown precipitate was formed in and around the epithelium, 
which, far from exfoliating, was cemented more firmly in place, 
and the effects of the nitrate were never transmitted beyond the 
epithelium to the gland cells. The coloration of the cells seemed 
due to simple imbibition. But on the living subject, the intro- 
duction by endosmosis of the foreign substance, excited nutri- 
tive reactions; through the same endosmosis of living cells, the 
irritant was transmitted much further than was possible by the 
imbibition in dead or dying cells. There must have been a 
greater afflux of blood to the stomach under the influence of this 
extensive glandular irritation, although no traces of hyperaemia 
remained after death. Finally the contact of the silver solution 
with the mucous membrane must have been many times repeated. 
Few conclusions can be drawn from these few observations. Yet 
the following may, perhaps, be justified: 

1st. The action of nitrate of silver upon living tissues is 
different from that exercised upon tissues whose vital connections 
have been severed, however recently. 

2d. In the latter case an extremely weak solution gives a 
brown precipitate at the edges of the epithelial cells, and prob- 
ably between them. This precipitate is formed almost in- 
stantaneously. If the solution be stronger, or the contact a 
little prolonged, the entire cell is colored, except the nucleus, 
This is a proof that the coloration depends on passive imbibition, 
and not on the vital activity of the cell. The relation of the 
silver salts to the nucleus seems to be exactly opposite to that of 
carmine. The weak solutions color the entire epithelitun, but 
leave the glandular tissue untouched. A rather concentrated 
solution produces a precipitate only in the superficial layers of 
epithelium. The coloration of these layers, however, was not 
more intense with a strong solution than with one sixteen times 
weaker. It is possible, however, that stratified pavement epithe- 
lium offers more resistance to the imbibition than do single rows 
of columnar epitheliimi. 

3d. The single application of a strong solution of nitrate of sil- 



Action of Nitrate of Silver 297 

ver to a living epithelial surface produces the same effect as the 
more prolonged contact of a weaker solution, with membrane just 
removed from the body. In both cases the silver forms a superfi- 
cial deposit, not always extending throughout the epithelial lay- 
ers, never beneath them. 

4th. On the living membrane a very weak solution, whose con- 
tact is prolonged, or frequently repeated, causes the deposit of 
silver in or around the epithelium, which facilitates its exfoli- 
ation, and consequent destruction. At least, this has been 
shown to be the case with the columnar epithelium of the 
stomach. 

5 th. The subepithelial glandular and connective tissue is irri- 
tated coincidently with, or consecutively to, this exfoliation. The 
irritation of the gland elements assimies the form characteristic of 
acute desquamative catarrh. There is cloudy swelling, increased 
size, and more intense carmine coloration of nuclei; loosening and 
even complete separation of cells, singly, or agglutinated in casts. 
The casts of the peptic glands in the specimen are strictly anal- 
ogous to those shed from the uriniferous tubes, when their epithe- 
lium has been submitted to the influence of some irritating sub- 
stance eliminated through them . 

6th. The agglutination together of the cells that separated so 
easily from the wall of the tube, would seem to imply that the sil- 
ver was first deposited at this latter point, surrounding the gland 
cells as it had the epithelium. 

7th. It is noticeable that the walls oi these cells, preserved in 
glycerine, were almost instantaneously dissolved by the addition 
of a very minute quantity of iodine. 

8th. Coagulation of free mucus by the nitrate seems to play a 
very small part in its action on mucous membranes. 

9th. Only microscopical examination of such apparent mucus 
can decide its real nature. In the case cited, and probably in 
many others, the so-called mucus consisted entirely of cells, 
coming not only from the epithelium (which had disappeared), 
but from sub-epithelial glands. 

loth. From what precedes, it may be inferred that in thera- 
peutical applications a weak solution of nitrate whose contact was 
prolonged, should exercise a more powerful and extended in- 
fluence upon tissues than a strong solution applied once and 
immediately decomposed. In all catarrhal affections of mucous 



298 Mary Putnam Jacobi 

membranes it is desirable, if possible; ist, to remove proliferated 
epithelium: 2nd, to remove and provide for the healthy renewal 
of the diseased cell elements ot £:lands. For both these purposes 
the first method should be more efficacious than the second. 
The effect on blood vessels has not here been studied. 



SPHYGMOGRAPHIC EXPERIMENTS UPON A HUMAN 

BRAIN, EXPOSED BY AN OPENING IN THE 

CRANIUM.^ 

Josie Nolan, aged ten, a very healthy Irish boy, had, eighteen 
months previous to observation, fallen and fractured his skull in 
the right fronto-parietal region. According to the mother's 
account, he remained insensible for two hours; but recovered 
consciousness about two hours after the fragments of broken 
bone had been removed by the trepan. The mother insists that 
from that time the wound healed rapidly, and that the child 
presented no morbid symptoms, not even fever. The history is 
evidently imperfect. At present there is an opening in the 
cranial bones, 2^ inches in the long diameter, i3^ inches trans- 
versely. The opening is situated in the right fronto-parietal 
regions, about 2 inches distant from the sagittal suture, towards 
which the long diameter is inclined at an acute angle. The open- 
ing is covered by a membrane, much thicker at the sides near the 
bones than in the middle. It is to be presumed that the central 
portion consists exclusively of dura mater, which, near the bony 
margin, is thickened by the addition of the remains of periosteum. 
The centre of this membranous covering is habitually somewhat 
depressed below the level of the cranial bones, but rises and falls 
in regular pulsations synchronous with those of the radial artery. 
Ordinarily, the effect of respiration is only distinctly seen in the 
sphygmographic trace; but, on forced inspiration, the membranes 
are clearly seen to descend still further below the level of the 
bones, and on forced expiration to bulge above it. Pressure upon 
the brain through these membranes causes no appreciable effect 
even on the pulse, and the boy, who has all the activity of his 
age, has, so far, never experienced the least inconvenience from 

' Reprinted from the American Journal of the Medical Sciences, 1878. 

299 



300 Mary Putnam Jacobi 

this partial exposure of the brain. Under no circumstances, of 
digestion, exercise, or the influence of the various drugs admin- 
istered during the experiment, was any change noticed in the 
colours of the membranes indicating increased vascularity in 
them. After exercise, they sometimes are bulging, but not 
always, and the effect of a temporary exertion rapidly disap- 
pears. When the boy is in a recumbent position, the level of 
the membranes is always higher than during the vertical posi- 
tion, whatever the level in the latter might be, or from whatever 
cause it had been effected. ^ 

The case offered a unique opportunity for the study of con- 
ditions affecting intra-cranial pressure. For this purpose, 
Mahomed's sphygmograph was adjusted to the head of the boy, 
in such a manner that the lever pad rested on the thin central 
portions of the membranes, the rest upon the bones, and steadied 
by an assistant. The adjustment was always made with the boy in 
a recumbent position, the head but slightly elevated upon a pillow. 

Before interpreting the traces, it is necessary to notice in what 
respects these must be expected to differ from those obtained from 
the expansion of an artery. It is obvious that the pulsating 
encephalon in our case differs from the pulsating artery: ist, 
by its greater proximity to the heart; 2d, by its vertical position 
over the heart; 3d, by the immensely greater surface receiving 
the shock of the cardiac systole, and through which must be 
disseminated the tidal wave of blood; 4th, by the greater volume 
of blood thrown against this surface; 5th, by the greater freedom 
allowed to the excursion of the part of the brain exposed; 6th, by 
the greater slowness with which its mass could collapse upon the 
blood wave. The trace from the artery corresponds to the move- 
ment of the entire mass of fluid contained in it. But while the 
pulsations of the encephalon are due exclusively to the influx of ar- 
terial blood, this fluid is only one of three which are moving simul- 
taneously in the pulsating mass, the others being the venous blood 
and the cephalo-rachidian fluid. 7th, the final difference to be no- 
ticed in the much greater influence of respiration upon the amount 

' Since writing this paper I have seen an article in the Centralblatt for 1877, 
describing analogous experiments upon a woman's brain exposed by carcinoma. 
The experiments did not test the influence of drugs; but the conclusions so far 
as regards the normal movements of the brain agree with mine. See Central- 
blatt, Mai 12, 1877. Giacomini u. Masso, Beweg. des Gehirns. 



Sphygmographic Experiments 301 

of blood contained at a given moment in the brain, as compared 
with that contained at the same moment in the radial artery. 

These various circumstances will each have a specific effect 
upon the sphygmographic trace. Thus, the first five peculiarities 
enumerated will combine to give a much greater amplitude to the 
curve, or an immense increase in the height of the ascension line. 

Owing to the fourth circumstance, the height of the tidal 
wave above the base of the percussion stroke will be greater; for, 
according to Mahomed, "this height indicates the amount of 
blood forced into the arterial system at each ventricular systole.*" 
From the sixth peculiarity, the tidal wave should be more sus- 
tained. On account of the third character, there should be few 
oscillations from secondary waves; thus, dicrotic and elasticity 
oscillations should be little marked. On the other hand, the 
multiplication of resistances offered in the brain by fulness of its 
veins, or tonic contraction of its arteries, should render obliquity 
of the percussion stroke, and even anacrotismus of the ascending 
line more frequent. Finally, from (seventh) the greater influence 
upon intra-cranial circulation exercised by the aspirating force 
of inspiration, a much greater depression should occur at the 
moment of inspiration in the ligne d' ensemble. 

The foregoing characters are all exhibited by the traces. 
The encephalic expansions, as uninfluenced by medicines, are 
shown in Trace No. I.; also. Trace No. VI. before the adminis- 
tration of atropia, and No. X. before coffee, and under the double 
influence of exercise and the digestion of a full meal. 



Trace I. 




Under pressure 5. 

Description. — Trace No. I. exhibits a peculiarity not observ- 
able in Traces VI. and X.; it possesses an anacrotic elevation, or 
an elevation on the ascending line. ^ 

' Med. Times and Gaz., vol. i., 1872, p. 129, 

* Elevation first studied experimentally by Landois. Die Lehre vom 
arterien Puis, Berlin, 1872. 



302 Mary Putnam Jacobi 

This is described by Mendel' as the character of the "pulsus 
tardus." In his schema, Landois succeeded in producing "ana- 
crotismus" under one of three conditions, namely, when the exit 
opening of the schematic artery is narrowed ; when the elasticity 
of its walls is diminished; and when, from increased volume of 
its contents, the internal tension is increased. Each of these 
conditions renders the distension of the tube by the systolic wave 
more difficult, hence prolongs the period of distension. Eulen- 
berg shows that an anacrotic elevation may be obtained by com- 
pression of the artery beyond the point at which the sphygmo- 
graph is applied. 

The other characters of this trace are, the well-developed tidal 
wave, or curve intervening between the percussion stroke and the 
aortic notch, and which, according to Mahomed, indicates the 
mass which has been thrown into the arteries by the cardiac 
systole; 2d, the deep inspiratory depression; 3d, the dicrotic 
elevation is slight, but more marked than in other traces. 

Interpretation. — These characters, together with the short but 
vertical percussion stroke, indicate increased cerebral resistance 
with a large volume of blood in active circulation. The larger 
the mass to be aspired into the thorax at inspiration, the more 
marked must be the depression in the line of cerebral expansions, 
or the ligne d' ensemble of the trace. ^ The slightly increased 
dicrotism in the trace is to be referred to the state of the mem- 
branes, which were depressed, and flaccid, not tense or bulging. 
It was clear, therefore, that, notwithstanding the considerable 
tidal wave, the brain was not at the time distended. In another 
trace, taken when the membranes were tense and bulging, 
dicrotism had entirely disappeared. It is to be inferred that the 
tonic resistance of the blood-vessels was at this time great. Such 
a condition would at once explain the great resistance offered 
to the cardiac systole, causing anacrotismus, and the diminished 
tension of the membranes, permitting slight dicrotismus. The 

' Arch. Virch., Bd. 66, p. 260. See also Eulenberg, Arch. Virch., Bd. 45, 
1869. 

^ The percussion stroke is shorter during inspiration than during expiration. 
Since at this moment the cerebral resistance is diminished, this shortening 
must be due, not to increased resistance, but to diminished force of the heart. 
This diminution is caused by the "negative pressure" exercised on the heart 
during the expansion of the thorax, and thus is secured a real intermittence 
in the blood-pressure to which the brain is subjected. 



Sphygmographic Experiments 303 

radial pulse showed high tension, and complete absence of dicro- 
tism. 

Hence, important corollary, we must conclude that intra-cranial 
pressure (such as would distend the membranes) is not necessarily 
in proportion to the tension of the cerebral blood-vessels, or to the 
height of their tidal wave, but may be just the reverse. 

Trace II. 





Pressure 5, two hours after 5 grs. of sulphate of quinia. Pulse 90. 

Description. — Trace No. JI. may be described as follows: 
Percussion stroke perfectly vertical and very high (by exact 
measurement one-third higher than in Trace No. X., the nexl 
highest observed). The angle between the percussion stroke 
and the line of descent of the preceding curve is very acute. 
Entire absence of anacrotismus. The systolic apex forms an 
acute angle, and is followed, not by a rounded curve, but by a 
horizontal, even slightly concave line. The tidal wave is very 
small. The line of descent is abrupt, and the dicrotic elevation 
very near to its terminus. Finally, the inspiratory depression 
in the ligne d' ensemble is enormous. 

The membranes bulged more at each cardiac systole than 
before the administration of the quinia, but were not tense. 

Interpretation. — The height and vertical direction of the per- 
cussion stroke are not exclusively due to increased energy of the 



304 Mary Putnam Jacobi 

cardiac systole, since when this is obtained by brandy the per- 
cussion stroke is much lower (see Trace No. IV.). Hence, in 
addition to the effect on the heart, there must be diminution of 
the intra-cranial resistance. The acute angle of the systolic 
apex implies an instantaneous momentary collapse of the cerebral 
blood-vessels after their distension by the percussion stroke. 
From the smallness of the tidal wave we must conclude that little 
blood is retained in the arteries at any given time. But the 
prolonged horizontal line between the systolic apex and the 
summit of the tidal wave, implies a sustained tension of the 
arterial walls. The line resembles that observed in traces from 
atheromatous arteries. But the abrupt line of descent indicates 
powerful elastic contraction of the arteries, contrary to what is 
seen in atheroma. 

Conclusion. — By a tonic dose of quinia, the energy of the cardiac 
systole is increased; the tonus and elasticity of the walls of cerebral 
blood-vessels are also increased, so that the blood is forced rapidly on 
through the capillaries, thus diminishing the resistance to the cardiac 
systole. More blood is admitted to the brain, but the intra-cranial 
pressure is lessened. 

Trace III. 




Two hours after 20 grs. of quinia. Pressure 5. Pulse 96. Temperature fallen 
one degree. Membranes depressed. 

Description of Trace III. — Percussion stroke vertical, but 
shorter than in Trace II. Systolic apex angle acute, and followed 
by descending instead of horizontal line. Tidal wave unequally 
developed, in some curves almost absent, in all very small, and 
far below the level of systolic apex. 

Interpretation. — Diminished intra-cranial resistance to per- 
cussion stroke; nevertheless, small amount of blood thrown into 
brain, rapid and complete collapse of cerebral arteries. 

Conclusion. — Diminished energy of cardiac contractions, un- 
filled cerebral arteries, great diminution in intra-cranial pressure. 



Sphygmographic Experiments 305 

It is important to notice that the radial pulse taken at this 
time exhibited a relatively much larger tidal wave and higher 
tension than was shown by these cerebral traces. We should 
infer therefore that the dimintition of intra-cranial pressure was 
out of proportion to the general diminution of pressure in the arterial 
system comiected with sedation of the heart. 

Description of Trace IV. — Percussion stroke not quite vertical, 
much shorter than after quinia; systolic apex forming a right, 
instead of an acute angle; tidal wave greatly developed; line of 
descent oblique and gradual ; angle between it and the following 
percussion stroke rather wide; dicrotism scarcely perceptible; 
inspiratory depressions not very marked, and much prolonged, 
comprising four curves, while the period of expiration comprises 
three. 

Trace IV. 




Pressure 5. After 3 drachms of brandy. Pulse 104. Membranes tense 



\ 



bulging. 



The membranes were tense, bulging, and affected by a pecu- 
liar heaving pulsation, not seen in any other case; the pulse was 
104. 

Interpretation. — Increased mass of blood in brain; increased 
resistance to percussion stroke dependent on this, and less than 
that which would be associated with contracted arteries; ' (see 
Trace I.) slow collapse of arterial walls, notwithstanding rapid 
circulation; increased duration of inspiration; slow aspiration 
of blood from brain. 

Conclusion is mainly expressed in the interpretation. The 
increased force of the heart is indicated by the radial pulse; its 
effect on the brain as shown in the trace, is partially compensated 
by the increased intra-cranial resistance. The cerebral blood- 
vessels are dilated, implying diminished tonus of their walls; the 
intra-cranial pressure increased. 

' Hence the percussion stroke, though short, is not anacrotic. 



3o6 Mary Putnam Jacobi 

Trace V. 




After 5 gtts. tincture belladonna ter in die for four days, and 5 gtts. every three 
hours on fifth day. Pulse 108. Pupils moderately dilated, mem- 
branes bulging, not tense in recumbent position. 

Description of Trace V. — General resemblance to Trace IV. 
under brandy. Percussion stroke one-fifth higher than in Trace 
IV.; systoHc apex a right or slightly obtuse angle; tidal wave 
developed about as much as with the brandy; line of descent 
gradual, without dicrotism; absence of inspiratory depression; 
rise of entire ligne d'ensemble, as if from prolonged expiratory 
effort. All the characteristics of the trace were developed un- 
der a pressure of four ounces, as was not the case with brandy; 
but the percussion stroke was then higher than is represented in 
Trace V. The membranes did not bulge at all when the boy was 
vertical. 

Interpretation and Conclusions. — Mass of blood in the brain 
increased about the same as after brandy; but intra-cranial pressure 
less (as shown by condition of membranes, and response to lower 
pressure of sphygmograph) . Expiration prolonged. 

Remarks. — From the traces alone it is rather difficult to under- 
stand why the tension of the membranes should have been so 
great with the brandy, and so slight with the belladonna; the 
rapidity of the circulation was almost the same in the two cases 
(pulse 104 and 108). The difference probably depends on accel- 
erated capillary circulation in the case of belladonna, and retard 
of the same after brandy. 

Trace VI. 




Before atropia, membranes depressed. 



Sphygmographic Experiments 

Trace VII. 



307 




30 minutes after, 5*5 gr. atropia, subcutaneously. Pulse 120. 

Description. — Trace VII. Half an hour after ^V gi"- atropia 
shows, as compared with Trace VI., taken just before; that the 
percussion stroke is double the height, and more nearly vertical; 
the anacrotism has disappeared; the angle of the systolic apex 
rounded, but followed by descending instead of ascending line; 
tidal wave much diminished; dicrotic elevation increased, and 
nearer by one-fifth to the percussion stroke — that is, the dura- 
tion of the ventricular systole is one-fifth less. Inspiratory de- 
pression remains the same, slightly marked, and comprising a 
single curve. The membranes were raised, but neither tense nor 
bulging. The radial pulse had become dicrotic. 

Interpretation. — Relaxation of cerebral blood-vessels; conse- 
quent diminished intra-cranial resistance to percussion stroke; 
more rapid collapse of arterial walls ; diminution in mass of blood 
retained in brain. 

Conclusion. — Diminution of intra-cranial pressure, but in- 
creased amount of blood passing through brain in given time; on 
account of accelerated cardiac action and diminished resistance to it. 

Description. — The peculiar effect produced by the drug is not 
perceptible in any individual trace alone, but in a comparison 
between the traces taken under moderate pressure (four and five 
ounces. Trace IX.), or under higher pressure (six ounces, Trace 
VIII.). In this the ascending stroke is anacrotic, in the others 
not. The tidal wave is also much less developed. 



Trace VIII. 




) 



Pressure 6. 



Interpretation. — The increase in pressure of the sphygmo- 
graph lever is transmitted to the cerebral arteries, so as to offer 



3o8 



Mary Putnam Jacobi 



decidedly increased resistance to the ventricular systole, and 
instead of developing the percussion stroke, breaks it. That 
such slight increase of pressure is able to cause anacrotismus, 
shows that tlie force of this systole, i. e., of the heart's action, has been 

Trace IX. 




2 J hours after i gr. tartar emetic. No vomiting. Membranes apparently 
tense, bulging. Pulse 112. Pressure 5. 

weakened relatively; that the intra-cranial pressure is not only 
diminished, but is easily overcome by external pressure ; in other 
words, that the walls of the arteries are relaxed. This peculiarity 
is not observed in any other trace, even that of the sedative dose 
of quinia, but is confined to the nauseating dose of tartar emetic. 
After vomiting, the intra-cranial pressure is raised, and resists 
the higher pressure of the sphygmograph. 

Trace X. 




Pressure 5. Before coflEee, pulse 112. Membranes tense, bulging. 
Trace XI. 




Pressure, 5. Half an hour after 4 oz. strong infusion coflfee. Membranes much 
depressed. Pulse 112. 

Description (Trace XL). — Absence of inspiratory depression, 
which has been marked in Trace X. Percussion stroke shortened 
to one-fifth the height, oblique, instead of vertical ; higher under 



Sphygmographic Experiments 309 

pressure 6 than 5. Diminution of tidal wave. The membranes 
were depressed, which had been bulging. The radial pulse 
remains the same in rapidity, and also in the form of the sphygmo- 
graphic trace (not here given). 

Interpretation. — From this last fact it is evident that the per- 
cussion stroke has not been shortened by weakening the force of 
the cardiac contraction. The shortening must, txierefore, be 
due to an increased resistance in the brain. As there is not an 
increased mass of blood in the brain, the resistance implies in- 
creased tonicity — increased contraction of blood-vessels. This 
tonicity is only overcome by greater external pressure; hence 
percussion stroke is more developed under pressure 6 than 5 
(reverse of tartar emetic). 

Conclusion. — The amount of blood circulating in the brain is 
smaller, but it is brought to nerve tissues under increased pressure; 
hence assimilation of nutritive material should be increased in 
rapidity, if lessened in quantity. The intra-cranial pressure, on 
the whole, i. e., against the membranes, is diminished. 

Trace XII. 




Presstire 4. Three hours after twenty grains of bromide of potassium. 
Trace XIII. 




Pressure 5. Pulse 76; membranes depressed below cranial level. 

Description. — Great development of tidal wave, perceptible 
under all pressures. At pressure 4, percussion stroke so oblique 
as to merge into tidal wave. Trace resembles that from an 
aneurismal tumour.' Under pressure 5, percussion stroke some- 
times vertical, sometimes oblique. Line of descent prolonged 
and gradual, without trace of direction. 

Interpretation. — The trace must be considered in connection 
' See trace given by Mahomed, Medical Times and Gazette, 1873, p. 222. 



310 Mary Putnam Jacobi 

with the facts, that the membranes had become depressed, and 
the tidal wave of the radial pulse extremely small, under the in- 
fluence of the bromide. It is to be inferred, therefore, that the 
large tidal wave in the cerebral trace does not depend upon an 
unusual amount of blood thrown into, or contained in, the brain, 
but upon unusual obstacles to its passage out of the brain. This 
implies a contraction of the smallest blood-vessels and capillaries, 
the larger remaining the same, and thus offering no other obstacle 
to the ventricular systole than the prolonged retention of blood in 
them; the latter causing increased lateral pressure, identical with 
that of a large tidal wave. 

Conclusion. — The intra-cranial pressure, on the whole, i. e., 
against the membranes, is diminished; but the brain tissue is sub- 
jected to a mechanical pressure from fulness of the vascular canals 
before the point where they begin to be nutritive, and because of 
relative exclusion of the blood from the latter. 

Remarks. — The descriptions of the traces of coffee and brom- 
ide read a good deal alike, except in regard to the tidal wave; but 
the traces are conspicuously different. The difference probably 
depends on the different rate of the circulation, on the different 
direct action of the drugs on the nerve tissues, and on the exercise 
of lateral pressure in the nutritive blood-vessels in the case of the 
coffee; in the canals leading to them, in the case of the bromide. 
In the case of the brandy an increased tidal wave was interpreted 
as evidence of dilatation of cerebral blood-vessels, because of the 
visible increase in the tension of the cerebral membranes and the 
state of the radial pulse which coexisted. 

The characteristic trace of the bromide was not developed 
until three hours afters its administration. It was most char- 
acteristic at a low pressure (4). It is not believed that the whole, 
or even the greater part of the physiological action of bromide 
of potassium can be explained by this effect upon the cerebral 
blood-vessels. 

To what extent the conclusions, drawn from these observa- 
tions, are in accordance with existing theories, may be considered 
on another occasion. On this, we content ourselves with regis- 
tering the facts. 



ACUTE FATTY DEGENERATION OF THE NEW-BORN.^ 

The following case offers, we believe, an interesting illustra- 
tion of a recognized, but still rare and not completely understood 
disease. 

Early in the past year, Mrs. H. asked my advice under the 
following circumstances: She had been married twelve years, and 
her eldest and her only surviving child was then eleven years old. 
I have forgotten the fate of the second child. The third was 
bom prematurely at seven months, and died within twenty-four 
hours after birth. The fourth was apparently healthy for three 
or four days, then began to have hemorrhages from the navel 
which resisted the application of iron styptics, and to whose 
repetition the child finally succumbed on the eighth day after 
birth. The fifth child was born dead at term — a week after the 
cessation of all movements. During this fifth pregnancy, Mrs. 
H.'s health, which previously had been irreproachable, had 
suffered a good deal, and she had noticed that her abdomen 
remained much smaller than in former pregnancies. The child 
at birth was said to have been very small, but no exact measure- 
ments were taken. After this confinement, Mrs. H. recovered 
her health completely. At no time, so far as could be ascer- 
tained by the history, did she present symptoms of endometritis, 
still less of syphilis. After the misfortune of the fifth confine- 
ment, she was advised, by a well-known German physician of 
this city, that, in the event of another pregnancy, she should 
watch the movements of the child carefully, and should they, 
near term, begin to grow weaker, that she should at once report 
the case to a physician, who might save the child by bringing 
on a premature confinement. 

It was for precisely this exigency that Mrs. H. consulted me. 

' Reprinted from the American Journal of Obstetrics, 1878. 

3" 



312 Mary Putnam Jacob! 

About a year after the fifth confinement, she again became preg- 
nant, and was now two weeks before term. During the period of 
gestation her health had been uninterruptedly good, and the 
movements of the child vigorous, until a few days previous, 
when they had begun to grow much weaker, and, warned by her 
previous experience, she was fearful that they might soon cease 
altogether. 

Upon examination I found the child apparently well-developed, 
the head presenting in the first position, the amniotic liquor in 
sufficient abundance, but not excess. The uterine souffle was 
loud and distinct, but the most careful search failed to discover 
the fetal heart, although the spontaneous movements of the 
child showed that it was still alive. It was evident, therefore, 
that the heart's action had begun to flag, under some unknown 
morbid influence, probably identical with that which had caused 
the death of the third and the fifth child. It was evident, 
further, that if this lethal influence depended on any lesion of 
the fetal viscera, a premature confinement would rather hasten 
death than avert it; while, if it were due to some morbid condi- 
tion of the placental or umbilical circulation, this expedient 
might possibly save the life of the child, as, in view of the pre- 
vious history, there was so much reason to suppose that the 
child would die if left to itself. I determined to act on the hypo- 
thesis which afforded the only excuse for action or hope of safety, 
and, confirming the previous opinion, advised artificial delivery, 
to which the parents readily assented. The cervix was extremely 
soft and dilatable, and by means of Barnes' dilators, labor pains 
were induced in about twenty-four hours. The child (a girl) was 
born seven or eight hours later, and, although rather small, 
seemed fairly vigorous. It cried immediately after birth, and 
showed no sign of asphyxia. The cord was to external appear- 
ance healthy. The placenta adhered for nearly an hour, and 
then was removed by artificial detachment, and torn during the 
process. But that all fragments were entirely removed from 
the uterine cavity was demonstrated, if necessar3% by the rapid 
and complete recovery of the mother. 

In securing the cord, after the child had been washed by the 
nurse, I took the precaution to apply two ligatures, as tightly as 
possible. I then left the child in apparently a very satisfactory 
condition, but two hours later, four hours after birth, was recalled 



Fatty Degeneration of New-Born 313 

by the tidings that an alarming hemorrhage had just taken place 
from the cord. The nurse compressed the cord with her fingers, 
and a neighboring physician, summoned while awaiting my 
arrival, found that this manoeuvre had nearly arrested the 
hemorrhage just before he came in. The child, however, was 
perfectly blanched, and to prevent, if possible, a recurrence of 
the danger, the doctor wound an elastic ligature tightly around 
the cord, from its free end to its cutaneous surface, not encroach- 
ing upon the latter He confirmed the statement of the nurse, 
that the blood had been seen to ooze from a point above the upper 
ligature, just at the junction of the mucous and cutaneous 
surfaces of the cord. At this point a minute tear was 
perceptible. 

I did not see the child until nearly an hour after the acci- 
dent. By that time color had returned, there was sufficient 
warmth, and a few drops of brandy in water were readily swal- 
lowed. The child was left wrapped in cotton-wool, and perfect 
quiet enjoined. This was at noon. 

At four o'clock in the afternoon, when recovery from the first 
accident seemed complete, I resolved to take the last precaution 
against its repetition, which seemed only too probable, by passing 
a couple of hare-lip pins at right angles to each other through the 
cutaneous base of the cord, and winding a ligature tightly around 
them, as in the strangulation of a nevus. The child was not 
moved from its cotton-wool nest during the little operation. 
Neither at this time nor later was there any disturbance of 
respiration. At six o'clock, it was doing very well; at ten, as I 
entered the room, the mother exclaimed with great satisfaction 
• that the baby must be growing stronger, for it had been scream- 
ing loudly for half an hour, and its cries had only just ceased. 
The quiet was ominous, and on approaching the child I found 
that the face had again become perfectly white, and that it had 
ceased to cry because it had ceased to breathe. The heart still 
beat feebly, but in a few minutes its pulsations also ceased, and 
life was completely extinct. Upon removing the coverings, I 
found that a slight amount of oozing had again taken place at 
the navel. There was none, however, around the hare-lip pins. 
This slight hemorrhage seemed altogether insufficient to account 
for the death. The real cause of death was revealed at the 
autopsy made twenty-four hours later. 



314 Mary Putnam Jacobi 

Autopsy 

Abdomen. — Several teaspoonsfuls of fresh fluid blood were 
found in the peritoneal cavity, some lying on the surface of the 
intestines, more gravitated into the flanks. There was no 
hemorrhage of the intestine, either into its coats or into the 
cavity. No trace of peritonitis. The blood seemed to have 
come chiefly from a rupture of the umbilical vein, between the 
navel and the liver, for in the connective tissue surrounding it, 
about half an inch above the navel, was a blood-clot the size of 
a French bean. 

No hemorrhages were discovered in the liver, spleen, or kid- 
neys, but minute submucous hemorrhages were scattered through 
the stomach. 

Thorax. — Here a most peculiar appearance was presented. 
The lungs were fully expanded, and collapsed imperfectly on the 
removal of the sternum. Scattered over their entire surface 
were numerous hemorrhagic spots, whose pleural area varied in 
diameter from a few lines to half an inch. The depth of these 
foci was generally about the eighth of an inch. The deep ex- 
tremity was somewhat smaller than the superficial, but in no 
case did they oflPer the wedge-shape characteristic of embolic 
infarcti. Similar hemorrhagic spots were disseminated through- 
out the parenchyma of the lungs. Between these spots the 
lung-tissue was normal to the naked eye. 

There was no effusion into the pleural cavity. There were 
no macroscopic alterations of the heart. The cranial cavity was 
not opened. 

Microscopic Examination 

Umbilical cord. — The umbilical vessels were examined exter- 
nally to the abdomen, and also for a short distance above and 
below the internal surface of the navel. All the sections were 
normal. 

Liver. — Examination of sections at a low power in no case 
succeeded in discovering the distinct separation into lobules, 
which is usually so easy to demonstrate on the liver of a new-bom 
child. At the same power, the larger bile ducts were observed 
to be surrounded by tissue, colored bright blue by the hematoxy- 
line, in striking contrast to the pale color of the rest of the sec- 
tion. A higher power resolved these blue bands into masses of 



Fatty Degeneration of New-Born 315 

round nucleated cells. The liver-cells were filled with fine fat- 
granules, which in no case were aggregated into globules. The 
size, shape, and nucleus of the cells were preserved, the nucleus 
coloring deeply with hematoxyline. 

Kidneys. — The epithelium was degenerated both in the cortex 
and in the medullary portion, but the process was much further 
advanced in the convoluted tubes than in the straight. In some 
of the tubes the epithelium was completely broken down, the 
nucleus gone in others, while the cells were full of fine granules; 
the nucleus was preserved and distinctly colored. The Mal- 
pighian glomeruli were generally intact, but in some cases the 
epithelitun covering them was degenerated like that of the tubes. 
In some places, quite a large area of the microscopic section was 
so completely degenerated that it appeared a uniform pale-yellow 
color, no nuclei remaining to take up the color of the staining 
fluid. In other places again, a small number of the tubes would 
appear completely normal. There was no proliferation of 
epithelium, and the lumen of the tubes was nearly always free. 
The connective tissue was not increased. The blood-vessels 
showed a few fat-granules in the tunica media. 

Stomach. — The sections of the stomach did not show any de- 
generation of the glandular cells, and were not sufficiently suc- 
cessful to demonstrate the condition of the cylindrical epithelium. 
On one section was found a mass of blood-corpuscles effused just 
at the base of the glands. The submucous blood-vessels showed 
the same sparse scattering of fine black granules between the 
nuclei of the muscular coat as were found in the renal vessels. 

Lungs. — Blood-corpuscles were scattered in abundance 
throughout every section, sometimes aggregated into masses, 
when the section had passed through a focus of hemorrhage, 
sometimes sparsely disseminated. The capillaries all contained 
blood, and the loops of vessels which encircled the alveoli looked 
as if they had been artifically injected. In some cases, these 
loops almost entirely occluded the alveolus. There was also a 
great abundance of epithelium in various stages of fatty degenera- 
tion. In some cases the epithelium had broken down into fatty 
detritus. These appearances have been described in cases 
hitherto related. But one feature in this case, of which I have 
not found any previous mention, was the appearance of fat- 
granules in great abundance in the muscular coat of the arteries, 



3i6 Mary Putnam Jacobi 

interspersed among the nuclei. These granules dissolved in ether, 
and resisted acetic acid. 

In two sections were discovered the point of rupture of 
medium-sized blood-vessels, with a stream of blood-corpuscles 
pouring through. 

Heart. — The muscular fibres of the heart contained fat- 
granules, but in excessive abundance. 

The case above described was evidently one of the rare 
disease first described by Hecker and Buhl in 1861, under the 
name of "acute fatty degeneration of the new-bom." Buhl's 
description' is as follows: "The lungs contain smaller or greater, 
tolerably circumscribed hemorrhagic infarcti; the bronchi con- 
tain pure blood or bloody mucus. The parenchyma of the limg 
is somewhat edematous ; the pavement epithelium filled with fat- 
granules. There is, further, fatty degeneration of the muscular 
fibre of the heart, and of the epithelium of the kidneys and liver. 
As a consequence of the pulmonary and cardiac lesions, the 
child soon shows symptoms of asphyxia and cyanosis; and as a 
consequence of the hepatic degeneration becomes icteric." 
Buhl attributes the multiple hemorrhages to alterations in the 
composition of the blood and the texture of the blood-vessels, 
both probably dependent upon the "acute nephritis and hepa- 
titis." 

In the Arch, fiir Gynaek., Bd. x., Hecker describes a new 
case of this disease. The child died in fourteen hours, after a 
slight hemorrhage from the navel quite insufficient to explain 
the catastrophe. The icterus was present at birth, and intense. 
At the autopsy were found numerous subpleural ecchymoses, 
large wedge-shaped pulmonary infarcti, fragility of walls of 
pulmonary vessels. There was blood in the pericardium, stom- 
ach, and intestine; the liver was pale and fatty; the heart soft 
and fragile; the spleen enlarged. In another case, reported by 
the same author, the blood was leukemic. Hecker remarked 
that this disease is so rare that it has scarcely been mentioned 
in literature since Buhl's first description of it was given. Miiller 
in a chapter devoted to acute fatty degeneration of the new- 
bom in Gerhardt's Cyclopedia, ^ only quotes five articles on the 
subject; of these only two^ describe the disease in the human 

' Klinikfiir Geburtskunde, 1861. ' Bd. ii., 1877. 

3 Hecker u. Buhl, loc. cit., and Hecker, Monats.Jiir Geburtskunde, Bd. xxix. 



Fatty Degeneration of New-Born 317 

subject. Furstenberg^ describes an analogous affection in the 
new-born of domestic animals. Roloff writes about young 
pigs- and foals. ^ The latter case is really an acute malignant 
osteitis, and has but very slight resemblance with the morbid 
condition which occupies us. Muller himself contributes nothing 
original to the subject. 

Three symptoms are prominent in the clinical history of this 
disease: umbilical hemorrhage, cyanosis, icterus; the latter 
constantly increasing until the moment of fatal termination. 
Of these, the first, or umbilical hemorrhage, was alone present 
in our case. It occurred earlier (two hours after birth) than in 
any case of which I can find a record. According to Hennig, of 
all cases of omphalorrhagia, the greatest number occur on the 
seventh day, that is, at or after the fall of the cord. He only 
counts 7 cases out of 135, as occurring on the first day. Accord- 
ing to Bouchut, the greatest frequency is from the third to the 
ninth day. Tanner only mentions the cases which occur after 
the fall of the cord. Although the accident is itself infrequent 
(Hennig reckons it as occurring once in 5,000 children), only a 
certain proportion of cases are to be attributed to generalized 
fatty degeneration. The belief that the hemorrhage principally 
depends upon imperfect ligature of the cord is widely diffused, 
both among the laity and in the profession, and has been not 
infrequently the basis of suits for malpractice. Thus Cripps 
Lawrence* declares that early hemorrhage is from the funis, 
and easily controlled by prompt ligation, even when the blood 
comes from the side of the cord. In the latter case, the accou- 
cheur is innocent of carelessness ; but the ordinary ligature must 
be complemented by another on the ventral side of the bleeding 
point. "With this exception," asserts the writer, "omphalor- 
rhagia preceding the fall of the cord is always due to imperfect 
ligature, or to imperfection in the material used for ligature, or 
to improper handling of the ligatured end of the cord." 

Mr. Lawrence admits that hemorrhage from the umbilicus, 
which he calls secondary, is a serious and "sometimes" fatal 
accident. He fails, however, to perceive that this hemorrhage 
may occur before, as well as after, the fall of the cord. Braun, 
in 1 87 1 , had pointed out that the main significance of umbilical 

' Virch. Arch., Bd. xxix. * Hn^^^ Bd. xxxiii. ^ Ibid., Bd. xliii. 

■» Obstetrical Journal, vol. iii., 1875. 



31 8 Mary Putnam Jacobi 

hemorrhage depended, not on the epoch at which it occurred, 

but on its origin from the umbilical vessels themselves, or from 
the "parenchymatous" vessels supplying the navel. The latter 
always depends on constitutional disease. Similarly Vogel 
describes the blood "welling up from the umbilical depression" 
left after the fall of the eschar. We have said that in our case, 
where the first hemorrhage took place two hours after birth, 
the blood was seen to issue from a minute opening at the junc- 
tion of the mucous and the cutaneous surfaces of the cord, hence 
must be classified with those cases called by Braun "parenchy- 
matous." 

The constitutional disease to which such parenchymatous 
hemorrhage has often been attributed is hemophilia. This has 
sometimes been inferred merely from the repetition of the 
accident in several children of the same family. Thus Jenkins* 
remarks that 17 mothers, among those whose histories he had 
collected, lost more than one child by umbilical hemorrhage. 
The same repetition of the accident was remarked in several 
children of Mrs. H. (our case). Hennig, however, observes that 
the tendency to multiple hemorrhages, characteristic of these 
cases, bears much more analogy to scorbutus than to hemo- 
philia. Grandidier^ declares that navel hemorrhage is only to 
the smallest extent the expression of the hemophilic diathesis. 
It is not especially frequent in families of "bleeders," and the 
children who survive the accident do not manifest hemorrhagic 
tendencies in later life. Out of 228 cases of omphalorrhagia, 
only 14 come from "bleeders," belonging to 11 hemophilic 
families. The bleeding diathesis is 13 times more frequent in 
males, but omphalorrhagia is more frequent in female children. 
The evidence seems conclusive that the accident of navel hem- 
orrhage is not, certainly in the great majority of cases, pro- 
duced under the influence of the constitutional disease with 
which it seems most naturally affiliated. 

When the umbilical hemorrhage has been preceded by 
icterus, which gradually deepens coincidently with the repetition 
of the bleeding, there is no hesitation felt in referring the acci- 
dent to the acute fatty degeneration which has been considered 
by Buhl as identical with the malignant icterus of adults. The 

^ Report on Spont. Umbil. Hem., 1858. 
' Die freiwillig. Nabelblut. Cassel, 1871. 



Fatty Degeneration of New-Born 319 

hemorrhage is then generally considered to be a consequence of 
the icterus ; as in acute liver atrophy of adults, the blood is sup- 
posed to be poisoned, "dissolved" by biliary acids absorbed from 
the degenerated liver-cells, and on this account to transude 
readily the walls of its containing vessels. 

The autopsy in our case, however, demonstrated: ist, that 
all the lesions proper to Buhl's disease may exist without the 
occurrence of icterus at any time before death. And 2d, that, 
in the absence of icterus, hemorrhages may occur — both umbili- 
cal and visceral — and in sufficient abundance to prove fatal. It 
is evident, therefore, that icterus is neither necessary to the 
diagnosis of the disease, nor to the production of its most dan- 
gerous symptom. 

The icterus is in proportion to the degree of degeneration of 
the hepatic cells. In our case, although these cells were filled 
with fat-granules, their contour and nuclei were intact, none 
had fallen into the detritus characteristic of the advanced stages 
of acute hepatitis. We must evidently conclude that, in this 
case, death occurred at a comparatively early stage of the 
disease. 

If the hemorrhage can be thus independent of the icterus, 
the sign of blood-poisoning, there is little reason for admitting, 
with Buhl, that it, or even the generalized fatty degenerations, 
result from the action of a special poison in the blood. The 
multiplicity of the hemorrhages indicates a cause for them that 
must have been generalized throughout all the tissues and 
organs of the body. 

Many morbid conditions are known to be characterized by 
multiple hemorrhages. Besides scurvy, hemophilia, and mal- 
ignant icterus already alluded to, it is well known that in 3^el- 
low fever and phosphorous poisoning, with their remarkable 
analogies to the last disease, and also in pernicious anemia, which 
in many respects approaches the first, visceral hemorrhages are 
as frequent, or even essential to the complete evolution of the 
morbid process. 

It is remarkable that anatomical alterations of the walls of 
blood-vessels have rarely been demonstrated in these hemor- 
rhagic diseases. In scurvy, Krebel' imagines that the small 
blood-vessels are partially paralyzed, a gratuitous assumption, 

^ Der Scorbut, 1862, S. 190. 



320 Mary Putnam Jacobi 

and which would not really explain the hemorrhages. In hemo- 
philia, many investigators have found no alterations of the 
blood-vessels, although Legg and Grandidier admit that, in a 
number of cases, their walls have been found abnormally thin. 
Immerman' says: "We must accept as an anatomical sub- 
stratum [of this disease], as an anomaly not exclusive to chlorosis, 
a general hyperplasia of the arterial vascular system, as also the 
partial fatty alteration of the walls of the blood-vessels which 
usually accompanies it." 

In regard to yellow fever, Haemisch- observes that, when 
the red corpuscles are destroyed, the blood decomposed [under 
the influence of the fever poison], the blood loses its power to 
nourish tissues [including the walls of vessels] ; hence their great 
fragility and consequent rupture. Ley den ^ observes that fatty 
degenerations are produced by all poisons which destroy blood- 
corpuscles. When the ductus choledochos was tied, and the 
absorption of bile necessitated by obstruction to its passage, ic- 
terus was first induced, then multiple ecchymoses. " The action 
of altered blood on a part [in producing fatty degeneration] is 
analogous to the effect of exclusion of blood by means of an 
embolus or a ligature." 

The majority of the writers on phosphorous poisoning refer 
the characteristic hemorrhages directly to the alteration of the 
blood, which alone is sufficient to cause transudation.'' But 
Klebs^ found in the adventitia of the small vessels, both veins 
and arteries, abundance of fine granules, partly albuminous, 
partly fatty. There was no alteration of the vessels of the 
brain, and this organ alone was exempt from hemorrhage. "The 
alteration of the vessels," remarks Klebs, "is the necessary inter- 
mediate lesion between the alteration of the blood and the pro- 
duction of extravasation. The latter never result from coarser 
ruptures of continuity of the vascular walls." 

On the other hand, as is well known, Cohnheim^ has shown 
that even a brief interruption to the nutrition of the walls of 
blood-vessels will so injure their integrity that their pores will 

» Ziemssen's Cycloped., art. Hemophilia, Bd. xii. ' Ibid., Bd. ii. 

3 Der Icterus, p. i8o. 

* Sec Lewin, Virch. Arch., Bd. xxi. Bernhardt, ibid., Bd. xxix. Wcgner, 
ibid., Bd. xl. Baunier, Caz. Med., 1868. Lebert et Wyss, Arch. Gen., 1868, 
s Virch. Arch., Bd. xxxiii. ' Ueher die Embol. Procesie, 1872. 



Fatty Degeneration of New-Born 321 

admit the transudation of red blood-corpuscles.' Cohnheim 
has further demonstrated, that, not only interruption of the cir- 
culation by ligature, but also venous stagnation will suffice to 
produce the deterioration.^ Now, in the lungs of our case was 
abundant evidence of extensive venous stagnation; the small 
blood-vessels and the capillaries were choked with blood. The 
cause of this arrest of the pulmonary circulation lay in the weak- 
ened force of the partially degenerated heart. In other cases 
on record, fatty degeneration of the cardiac muscles has been 
much more extensive than was noted in ours; and, perhaps 
correlatively, asphyxia has been a prominent symptom, while 
in our case it was entirely absent. But the flagging of the heart's 
action was shown even before birth, by the impossibility of dis- 
covering its sounds on auscultation. 

The hemorrhages in the lungs, the most extensive and re- 
markable revealed by the autopsy, were therefore explicable 
by one or more of several different lesions, ist. The fatty infil- 
tration of the walls of the blood-vessels. 2d, Nutritive altera- 
tion of these walls, not demonstrable to the microscope, and 
dependent upon, (a) acute poisoning of the blood; or on (b) in- 
tensely anemic impoverishment of the blood; or (c) on the 
venous congestion, itself caused by failure in the contractile 
force of the heart. 

What is the immediate cause of the fatty degeneration of 
the heart, of the blood-vessels, the epitheliums, and the gland 
cells, which underlies the hemorrhage and all other clinical 
symptoms of the disease? 

As already noticed. Buhl assimilates the disease to malig- 
nant icterus, and considers that an acute inflammation sets in 
shortly before birth and rapidly fulfils its course afterwards. 

For obvious reasons, the special clinical symptom of such an 
inflammation, namely fever, cannot be ascertained at the time 
the disease is presumed to commence. But fever has not been 
noticed after birth, in the cases of infants dying from acute 
fatty degeneration. To us, the facts in regard to the multiple 
fatty degenerations all point, not in the direction of inflamma- 

' Concerning the precise mechanism of this extravasation, and ingenious 
hypotheses on the nature of the pores, see Schklarewsky, Pflug. Archiv. Bd. i. 
(Ueber Diapedese.) 

*Virch. Archiv., Bd. xli., S. 220. 



322 Mary Putnam Jacobi 

tion, but of direct arrest of nutrition, by arrest of vascular 
supply. 

That diminution of the quantity, as well as alteration in the 
quality, of blood supplied to a tissue may induce fatty degen- 
eration in it is well known. Several recent experiments set 
this part in a very clear light. Zielonko' introduced two com- 
plex conditions into his experiment, when he gradually nar- 
rowed the entire aorta, and observed the effect on the kidneys. 
According to the degree of narrowing, he found albuminous 
tumefaction of the kidney, moderate hydronephrosis, and fatty 
degeneration of the epithelium. But in this case the rise of 
tension in the venous system must have been great enough to 
account for the results, as much as the arterial anemia. 

But Perl ^ imitated pathological conditions better, when he 
subjected dogs to repeated venesections, at intervals of five 
days. When three per cent of the body weight was abstracted 
by the bleeding, fatty degeneration of the heart was always 
produced. 

Von Platen ^ gradually compressed the renal artery by means 
of a silver clamp. This interruption to the circulation of the 
kidney was followed by various degrees of fatty degeneration of 
their epithelium. If only a single branch of the renal artery 
was compressed, the degeneration was limited to the territory 
supplied by it. 

Recklinghausen'' describes a cloak {" Mantel") of fatty 
infiltration around a hemorrhagic infarctus of the kidney. He 
observes that, after ligature or embolus of one branch of a renal 
artery, there will be necrosis in the centre of a territory supplied 
by it ; but fatty infiltration on the periphery, where an imperfect 
nutrition is maintained by means of collateral blood-vessels. 

So far as I know. Pepper is the only writer on pernicious 
anemia, who considers it as other than a primary blood-disease, 
characterized by rapid diminution in the mass of the blood, 
and in the number of its red corpuscles. Pepper, however, in 
a single autopsy, found an alteration in the medulla of the bones, 
resembling that described by Neumann in medullary leukemia; 

' Virch. Arch., Bd. Ixi., S. 267. 
' Virch. Arch., Bd. lix. 
3 Virch. Arch., Bd. Ixxi., Heft I. 
' Virch. Arch., Bd. xx., S. 205. 



Fatty Degeneration of New-Born 323 

and on the strength of this observation, this author ranks per- 
nicious anemia as a form of leukemic disease. ^ 

If, for the reason alleged in the footnote, we set aside this 
opinion, we should find all observers agreed in considering this 
"idiopathic anemia," and the fatty degenerations characteristic 
of it, as an exquisite clinical counterpart to the pathological 
experiments already quoted: to the experiments of Cohnheim 
and Arnold, showing the influence of denutrition of the walls 
of blood-vessels upon the production of hemorrhages; to those 
of Ponfick, Perl, Platen, and others, showing the influence of 
diminished afflux of blood in the production of fatty degenera- 
tions or infiltrations. 

"The general mass of blood is diminished; there is true 
oligemia; multiple hemorrhages are frequent; those into the 
retina almost characteristic. We shall not err if we attribute 
this development of a hemorrhagic diathesis to an alteration of 
the walls of blood-vessels, caused by the alteration in the quan- 
tity and the quality of the blood. Anatomical alteration of the 
vessels may be demonstrated in many cases." [So in the pul- 
monary vessels in our case.] 

"Clinical experience teaches that the diminution of red cor- 
puscles is the alteration of the blood which is most potent in 
determining the [acquired] hemorrhagic diathesis." [This can- 
not include hemophilia, where no such diminution exists.] "The 
hemorrhages, and the fatty degenerations of the heart, the intima 
of the arteries and capillaries, the hepatic cells, the renal epithe- 
lium, and the peptic glands, observed in various cases of perni- 
cious anemia, are explained by the diminution in the mass and 
in the corpuscular richness of the blood." ^ 

Biermer originally maintained that the visceral hemorrhages 
of pernicious anemia were always associated with fatty degen- 
eration of blood-vessels. But Miiller ^ failed to find this in 
quite a number of cases. "In these, other forms of nutritive 
alteration of the vessels must exist." 

' Am. Journ. Med. Set., Oct., 1875. This opinion seems to us unwarranted, 
for in pernicious anemia, the diminution of red corpuscles is not accompanied 
by a marked increase of the lymphoid elements of the blood. 

^ Immermann, Deutsches Archiv, Bd. xiii., p. 217. 

3 Ueber progressive Anamie. See also Gusserow, Archiv fur Gynaek., Bd. 
ii., 1871. Ponfick, Berlin. Klin. Wochen., 1876. 



324 Mary Putnam Jacobi 

The fetus is tolerably well protected from the influence of 
the poisons capable of producing "acute fatty degeneration," 
in the way Buhl and Hecker suggest.'' But, on the other hand, 
it is peculiarly exposed to alterations of nutrition, caused by 
variations in the amount of blood-supply. Disseminated lesions 
of the placenta, not visible to macroscopic examination, may 
destroy a sufficient number of villi to seriously diminish the 
quantity of nutritive material brought to the fetus. To an 
inflammation of the placenta, starting from the decidua, it is 
well known that Rokitansky attributed many cases of "tabes- 
cence of the fetus," and also most cases of "adherent placenta" 
and "placenta polypus." ^ As is also well known, the possibility 
of inflammation of the placenta has been denied, principally 
on the ground of the very small amount of connective tissue in 
it, and also on the absence of capillaries, except in the vascular 
loops of the villi. 

Maier, ^ however, has more recently described a lesion accept- 
ed as placentitis by Schroeder '' and Spiegelberg, ^ and which 
consists of a proliferation of the intervillous conjunctive tissue. 
This proliferation may begin either in rudimentary conjunctive 
tissue between the villi, or else in the adventitia of the arteries 
as a periartritis. This proliferation causes a compression of 
vessels and an atrophy of villi "which, if very extensive, must 
lead to the death of the child." Or again, the process may 
begin in a thickening of the decidua serotina, which becomes 
closely adherent to the altered placenta tissue [apparently by 
connective filaments binding together the free ends of the fetal 
villi and the maternal sinuses in which they float], so that the 
two can no longer be separated. From the altered serotina, 
innumerable processes pass into the placenta, and there connect 
with the increasingly thickening masses of conjunctive tissue. 

Neunsam ^ apparently described an advanced stage of this 
same lesion, under the name. Sclerosis of the Placenta. He 

' Hecker relates a case of "acute yellow atrophy " in a woman seven months 
pregnant, and ranks it with the acute fatty degeneration of the new-born. He 
thinks that, in both cases, some sudden decomposition of the blood occurs 
from causes hitherto unknown. {Monatschr. fiir Geburtskunde, 1865.) 

' Lehrbuch fur Path. Anat., Bd. iii., S. 545. 

3 Virch. Arch., Bd. xlv., 1869. •* Lehrbtich der Geburtskunde. 

i Lehrbuch der Geburtskunde, Bd. i., 1877. 

^Monatschr. der Geburtskunde, 1861, Bd. 17, p. 153. 



Fatty Degeneration of New-Born 325 

found, in the tissue of the latter, hard white places, showing no 
trace of normal cavernous structure, and the hyaline basement 
substance of the villi changed to conjunctive tissue, granular 
and cloudy.^ 

Schroeder remarks that it is this "cirrhosis" of the placenta 
which is the common cause of its adhesion to the uterus. The 
chances for the life of the fetus depend upon the extent to which 
the lesion progresses before birth. 

It is a misfortune that, in our case, as well as in the others 
like it which have been reported, the placenta was only cur- 
sorily examined. But the fact that it adhered closely to the 
uterine wall, and could only be detached with tearing, offers a 
strong presumption that sclerosis of the placenta existed. We 
may be permitted the probable hypothesis, which may easily be 
tested in other cases, that by such a lesion the blood-supply to 
the entire organism of the fetus was gradually diminished, as 
in the experiment of applying a ligature or a clamp to the aorta 
or renal artery, and that, under the influence of this oligemia, 
the nutrition of the blood-vessels became fatally impaired, and 
the glandular epithelium became fatty. 

It is noteworthy that, in previous confinements, Mrs. H. had 
also experienced an adhesion of the placenta. 

' Maier insists that the lesion described by him has no connection with this, 
but it is difficult to see why. 



CONTRIBUTION TO SPHYGMOGRAPHY^ 

THE INFLUENCE OF PAIN UPON THE PULSE-TRACE 

"A SUDDEN impression, however brief, made upon a sensitive 
nerve, always determines, as initial effect, or slackening or a 
diastolic arrest of the heart. "^ 

In these words M. Francois Franck sums up the results of 
numerous experiments, in which the effects upon the heart, 
of peripheric irritations, are delicately inscribed and analysed 
by means of graphic apparatus. The trigeminus was irritated 
by vapors applied to the nose, or by rapid burning of the nostril 
with a red hot needle; and the laryngeal nerves, by touching the 
mucous membrane of the larynx with a brush dipped in am- 
monia: the auricular branches of the trigeminus, branches of the 
cervical plexus, sciatic and crural nerves, were each irritated 
mechanically: finally, the abdominal fibres of the sympathetic, 
by pinching the peritoneum inflamed by means of previous 
exposure to the air. "In all these cases, the arrest or slacken- 
ing of the cardiac pulsations was observed as a constant phenom- 
enon." (p. 255.) This would have passed unperceived, but for 
the modification introduced in the graphic tracing of the cardiac 
pulse movements. 

It occurred to me that the foregoing experiment might be 
exactly reproduced on the human subject, by observing the 
sphygmographic tracing of the pulse at the moment that a 
dentist should touch the exposed nerve of a tooth. Through 
the kindness of Dr. Kidder, an opportunity was afforded to test 
this suggestion. Mahomed's sphygmograph was carefully ad- 

' Reprinted from the Archives of Medicine. 
^ Travaux du laboratoire de M. Maroy, annfe II, 1876, p. 227. 

326 



Contribution of Sphygmography 327 

justed to the arm of a lady, who, at the time, was suffering no 
pain, but whose teeth were about to be filled. 

Trace I. was taken while the upper part of the tooth was 
being scraped, an operation causing comparatively little pain; 



SCHAPlNt UPPER PART Or TOOTH 

* LITTLE PAIN 

FIG. I. 

the trace is regular, and the cardiac impulse strong and well 
sustained. 

In Trace II, the upper line is taken before any manipulation 
of the tooth. On the lower line at B, the probing begins, and 
at the same moment the base line falls, to rise again, but to con- 



BEfORE /WANIP. 




|e6. PROBE Q 



PROBE TOUCHES SENSITIVE PAI^T 
FIG. 2. 



tinue somewhat irregularly. At C the probe touches the sen- 
sitive nerve, and instantly the line falls, the cardiac pulse is 
altogether, though momentarily, arrested. 




FIG. 3. 



BEFORE /VflAftlP. 




FIG. 4. 



In Traces III and IV the same fall is also clearly seen at the 
moment that the nerve is touched, (points B), but the fall is 



328 Mary Putnam Jacobi 

not so complete, the needle not carried entirely off the paper, 
and the tracing is therefore resumed. 

These traces, therefore, afford an interesting confirmation of 
the law of Frangois Franck, that peripheric irritation of any 
sensitive nerve, in proportion to its intensity, inhibits the action 
of the cardiac ganglia. This is again a branch of the more 
general law established by the experiments of Goltz,' that the 
irritation of any one part of the nervous system is capable, 
under certain circumstances, of inhibiting the action of various 
other parts. 

' Beitrdge zur Lehre von den Functionen der Nerven centren des Frosches, p. 39. 



CASE OF FACIAL AND PALATINE PARALYSIS, AND 

LOSS OF EQUILIBRIUM, PRODUCED BY A 

FALL ON THE HEAD.^ 

Ralph Rosenstein, aged 2 years, was brought to the dispen- 
sary of the Mt. Sinai Hospital, on October 18, 1880; the mother 
stated that a week previous he had fallen off a chair to the floor, 
striking the back of his head. No especial effect from the fall 
was, however, observed during the two days first following the 
accident, but on the third day he began to droop; he allowed his 
head to fall forward, walked with a staggering gait, and finally 
refused altogether to walk, or even to stand. Previous to the 
fall, he was said to have walked well. Co-incident with the 
symptoms, he began to cough. 

On the day of examination it was found that he could stand ; 
coiild move his legs while supported in a standing position, and 
very freely while in bed; but would not stir from his place, even 
to follow the mother who pretended to lead the way. He then 
burst out crying, and sat down on the floor, but seemed unable 
to try to walk. During the examination he asked for water, 
and as he was drinking it was noticed that the water regurgitated 
through the nose. On inquiry it appeared that this had hap- 
pened ever since his fall, but the mother had not thought it worth 
mentioning. No diphtheria existed or had existed to explain 
this paralysis of the soft palate. The uvula was markedly 
deviated towards the left. The right angle of the mouth drooped ; 
thus there was evidently paralysis of lower branches of the right 
facial nerve, the staphylo palatine and buccal branches. But 
the upper branches were intact: the eyelids and the muscle of 

' Reprinted from the Independent Practioner, Baltimore, 1881. 

329 



330 Mary Putnam Jacobi 

the forehead presented a perfectly normal appearance. There 
was no deviation of the tongue; none of the eyeball; the pupils 
were unaffected. From the tender age of the child it was im- 
possible to ascertain whether any deafness existed on the right 
side or whether there was any sensation of vertigo. The morbid 
symptoms consisted therefore in paralysis of the right facial 
nerve and in loss of power to maintain equilibrium in an upright 
position without paralysis of the lower extremities. The dif- 
ficulty of walking seemed to be entirely due to dread of falling. 

Two localities suggested themselves as the seat of a lesion 
capable of explaining this group of symptoms. The first, some 
portion of the petrous bone that might include at once the facial 
nerve and one of the semi-circular canals of the internal ear. 

It is well known at present that lesions of these canals serious- 
ly interfere with maintenance of equilibrium of the body. Ex- 
periments have even determined the direction in which each 
canal seems to exercise an influence. Crum Brown' has so 
analyzed these influences as to bring them within the same gen- 
eral law as that of the co-ordinating centres in the cerebellum. 
According to this law, the inclination of the body in any given 
direction tends to excite the centre situated on the opposite side 
of the body in such a manner that the complete falling over is 
prevented by antagonism. In the labyrinthimic canals, accord- 
ing to a plausible hypothesis, the nerves are stimulated when 
the endolymph flows in excess into the ampullae at one extremity, 
the motion of the fluid being freely determined by the position 
of the head. The horizontal canals are all situated in the same 
plane, but their respective ampullae are turned in different direc- 
tions. When the head inclines to the right side, the endolymph 
flows from the ampullae into the canal; while at the same time 
on the left side it is flowing from the canal into the ampullae. 
The ampullary expansion of the left auditory nerve is therefore 
stimulated by the excess of pressure, and an impression con- 
veyed to co-ordinating centres in the cerebellum, which tends to 
restore equilibrium. Destruction of the horizontal canal on the 
left side should therefore be followed by a tendency to fall to the 
right, from loss of the antagonistic mechanism. According to 
Goltz (quoted by Ferrier, "Functions of the brain,") division of 
the auditory nerve will, in the frog, be followed by the same symp- 

» Journal of Anatomy and Physiology, May, 1874. 



Facial and Palatine Paralysis 331 

toms as division of the semi-circular canals. This latter fact 
alone could explain the circumstances of our case, supposing 
that the loss of equilibrium were due to injury of the petrous 
nerve. For although the aqueductus Fallopii carrying the facial 
nerve passes almost between the cochlea and the semi-circular 
canals above the vestibule of the inner ear, yet a lesion common 
to those canals and to the facial nerve, would necessitate a 
fracture of the bony floor of that aqueduct. The slight nature 
of the injury sustained by the child, and the transciency of its 
effects both precluded the supposition of so grave a lesion. 

Again: as the lesion of the facial was certainly on the right 
side, injury to the semi-circular canals, if existing at all, must 
have been on the right side also. But, as already stated, injury of 
the horizontal canal on the right side, is followed by a tendency 
to fall on the left, on account of loss of the mechanism which 
naturally compensates a tendency to fall on the left. In our 
case the child always fell on the right. 

This fact might at first seem to annul altogether the hypothe- 
sis of the petrous bone lesion. The fact that the upper facial 
remained intact might seem compatible with any form of peri- 
pheric lesion, and necessitate reference to the centres. The por- 
tion of the encephalon whose injury would be capable of inducing 
paralysis of the right facial nerve, and loss of equilibrium, is the 
inferior surface of the right lateral lobe of the cerebellum, near 
the median lobe, and also near the facial nerve after its emergence 
from the medulla. 

"The maintenance of equilibrium is an example of adaptive, 
responsive or asthetiko-kinetic action, depending on the co- 
ordination in some central organ of certain afferent impressions 
with special motor adjustments. The afferent factors of this 
mechanism are mainly of three kinds, namely, tactile, visual, 
and labyrinthic impressions. We are justified in concluding 
that the cerebellum is the central organ of this co-ordination." 
(Ferrier, p. 113). 

According to Nothnagel {TopiscJie Him krankheiten), in co- 
ordination of movements and loss of equilibrium are the only 
characteristic signs of lesion of the cerebellum.^ This is shown 
with special vacillation of gait, and with severe vertigo. Noth- 

' Of course, as the author especially notices, this symptom is not exclusive 
to the cerebellum. 



332 Mary Putnam Jacobi 

nagel adds, that if this symptom exist in cerebellar disease, it 
indicates a direct or indirect affection of the middle lobe of the 
cerebellum. According to the same authority, paresis or paraly- 
sis of the facial nerve is occasionally, although rarely observed, 
in lesions of the cerebellum: and is then always due to pressure 
upon the nerve after its emergence from the medulla, by means 
of some lesion, as a hemorrhage or tumor, sufficiently near the 
surface of the cerebellum to exercise an extra cerebellar effect. 
In such cases the paralysis resembles that due to lesions of the 
motor tract of the cerebmm in being confined to the buccal 
branches of the facial. 

Such a paralysis would therefore not correspond to that ob- 
served in our case, where the buccal lesion was much less prom- 
inent than that of the palatine branches of the portio dura. 
These branches are derived from the greater petrous nerve which 
is given off from the facial at the geniculate ganglion." (Longet.) 
The geniculate ganglion is situated at the first angle of the 
aqueductus Fallopii, and thus lesions of the portio dura, during 
their passage through this aqueduct are especially liable to be 
attended by paralysis of the palate; a comparatively rare se- 
quence of either completely central or completely peripheric 
lesion of the nerve. 

The distance is very small from the geniculate ganglion to the 
internal meatus, where the auditory nerve still lies side by side 
with the facial. It is conceivable that a slight hemorrhage 
should occupy all this space, and thus co-incidently affect the 
auditory nerve, the facial, and the branches emanating from its 
geniculate ganglion. 

The experiments of Goltz, already quoted, which, showing 
that section of the auditory nerve may have the same effect as 
lesion of the semi-circular canals, would explain why a lesion in 
the vicinity thus defined should occasion loss of equilibrium. 
The auditory nerve, though it represents neither the organ 
receiving labyrinthic impressions nor the central organ receiving 
them, unquestionably constitutes the path by which they are 
conveyed to that central organ, the cerebellum. A portion of 
the roots of the auditory nerve pass to the cerebellum in the 
restiform bodies, (Meyner) so that each auditory nerve is con- 
nected with the lateral hemisphere on the same side. 

According to Ferrier, experimental lesions of the lateral lobes 



Facial and Palatine Paralysis 333 

of the cerebellum, whether destructive or irritative, are followed 
by the same results as are lesions of the peduncles. The dis- 
placement of the body is sometimes toward the side of the lesions, 
sometimes toward the opposite side. The latter, observes 
Ferrier, is more likely to occur when the lesion is limited, the 
former when it is extensive. 

Hitzig, (Untersuch iiher das Gehirn, p. 203) pointed out that 
the passage of a galvanic current through the cranium was fol- 
lowed by a sudden sinking of the head towards the side on which 
the irritation is applied, i. e., where the anode is placed. Now 
an irritation transmitted to the lateral lobe of the cerebellum, 
along the auditory nerve, should have the same effect as this 
electrical irritation. Equilibrium would be disturbed from the 
unequal stimulus of the co-ordinating centres, and, as experi- 
ment shows, without clearly explaining why, the tendency might 
be to fall on the same side as the lesion. The case differs from 
that of lesion of the labyrinthic canals, affecting the terminal 
expansion of the nerve, because that implies destruction of a 
mechanism by which a tendency to fall towards the other side is 
habitually compensated, whereas, lesion of the trunk of the nerve 
coincides in effect with lesion of the lateral lobe of the cerebellum 
on the same side. 

From the foregoing reasons we have ventured to diagnose a 
hemorrhage, extending from the internal meatus through the 
aqueductus Fallopii as far as the geniculate ganglion, as the 
cause of the symptoms observed in the case of Ralph Rosenstein. 



INAUGURAL ADDRESS AT THE OPENING OF THE 

WOMAN'S MEDICAL COLLEGE OF THE NEW 

YORK INFIRMARY, OCTOBER i, 1880/ 

Ladies — It is a good plan, on the threshold of any important 
enterprise, to pause and take a survey of the field we propose to 
traverse ; otherwise we may lose our way, and arrive at the wrong 
goal at last. 

Every enterprise involves difficulties. Difficulties are in- 
separable from any condition of existence. The question there- 
fore always is, not "Are there any difficulties to encounter?" but 
"For precisely what difficulties must I prepare?" The difficul- 
ties involved in the study and practice of medicine are intrinsic 
and extrinsic; and we will consider each in its order. 

In addition it will be profitable to inquire what especial dif- 
ficulties attend the study of medicine by women ; and, finally, to 
point out some which we have practically encountered in the 
working of this school. 

The first intrinsic difficulty in medicine consists in the great 
mass of facts which it is necessary to know, and in the variety 
of sciences which must be understood in order to interpret these 
facts. There is a general impression among non-medical people 
that all medicine can be learned simply by listening to what sick 
people have to say for themselves ; that any one who has listened 
during a few months or years to such conversations knows all 
about medicine — is rich in experience; that what such an one 
does not know is not worth knowing. Now, in reality, such a 
method would not suffice to teach the pathology of a cold in the 
head, although a thousand sufferers related the details of their 

* Reprinted from The Chicago Medical Journal and Examiner, 1881. 

334 



Inaugural Address 335 

illness with the utmost loquacity. At the very outset of clinical 
study it is well to be impressed with this fact : namely, that what 
the patient has to tell you constitutes precisely the least impor- 
tant part of what you must learn about him in order to be able 
to understand his case, and to do him any good. This is not 
only true in regard to children, to insane people, to those who are 
for the time delirious or unconscious, or to those whose willful 
exaggerations or reticences evidently distort the description of 
their symptoms. It is true of every one who does not understand 
the pathological significance of one symptom as compared with 
that of another : true, therefore, of every one who is not himself 
a physician. Let us take an individual case — it makes scarcely 
any difference what. As serving to illustrate many points, I will 
select a case of fractured skull. The physician is siunmoned in 
haste, and learns that an hour previously the patient had fallen 
from a scaffolding to the street; had been picked up unconscious, 
and brought home in the same state; that shortly after reaching 
home he had vomited, but had not, as the saying is, yet come to 
himself. The physician finds the patient in bed, motionless and 
insensible. His eyes are closed, but if the lids be raised the pupils 
will be found to contract, perhaps sluggishly, to the light, and the 
lids quiver more or less if the conjunctiva is tickled. The breath- 
ing is slow and rather labored, and at each respiration the cheeks 
puff out as if the man were forcibly smoking a pipe. Perhaps 
from time to time one of the arms is raised and moved con- 
vulsively backwards and forwards, then falls again. The face 
is pale, but when the doctor lays his finger on the pulse he finds 
no sign of exhaustion ; the pulse is full and hard, and rather slow. 
He will notice that the clothes are wet with urine. In examining 
the head he finds on one side, near the vertex, that the hair is 
matted; and, separating the mass, he comes upon some clotted 
blood. He presses his finger in the center of the clot, and may 
find a depression below the level of the cranium. Perhaps 
when he presses on this depressed portion the convulsive motion 
of the arm will re-commence. On searching farther, he may 
notice a clear fluid running from the ear, on the same side with 
the visible fracture. Here is his case. Now, for the sake of sim- 
plicity, I have so stated it that, in regard to the main fact, the 
doctor is not called upon to make any diagnosis. There is no 
doubt about it; the man has fallen and fractured his skull. But, 



336 Mary Putnam Jacobi 

before the physician can understand either the extent or the con- 
sequence of this injury, he must be extremely familiar with the 
anatomy of the injured region. He cannot learn this anatomy 
from looking at the patient, nor at a hundred similar patients. 
He must have had the opportunity on many dead ones to dis- 
sect out all the parts, and study repeatedly their relations to 
each other. Then only could he know, in the first place, even 
that there was a brain inside the skull ! Further, that the piece 
of bone which had been driven in by the blow had probably torn 
the membranes covering the brain, and even the pulpy substance 
of this vital organ itself. He must remember the sinuses in the 
membranes, and the effusion of blood that poured out from 
them was probably now pressing on the surface of the brain. 
He must be able to tell, in order to furnish the basis for his 
physiological analysis of the case, just what part of the surface 
had been injured — the part whose irritation is known to cause 
convulsive movements of the right arm. He must be able, from 
his previous knowledge, to trace downwards the direction of an 
invisible crack, leading from the visible fracture to the base of 
the skull, and splitting another portion in such a way as to allow 
of the escape of the clear liquid from the ear. All this knowledge, 
and that of other details which I omit, must the physician bring 
to the case from the study of the first science on which medicine 
reposes — the science of anatomy. He then begins to trace the 
relation between the symptoms he has observed and the lesion 
he has discovered, by means of his knowledge of the functions of 
the parts involved — in other words, by his knowledge of phy- 
siology. By a violent shock the functions of important organs 
have been rudely interrupted. The physician who was not 
already well acquainted with these functions would be entirely 
unable to explain why a blow on the head should suspend or 
alter them. He could not even see any reason for the suspension 
of consciousness, of feeling, of power of movement, which has 
been induced by this blow. Still less could he understand the 
vomiting, the involuntary emission of urine, the convulsive 
movements of the arm, the puffing of the cheeks, the changes in 
the respiration and the pulse. In other words, unless he had an 
intimate acquaintance with the working of the machinery of the 
body while in order, he would be as little able to understand its 
disorder as a bricklayer to know why a watch had stopped, or a 



Inaugural Address 337 

shoeblack to mend a locomotive. But the analysis of the case 
is not finished. The fall of a living body from a height is an 
event not contemplated in the physiological workings of the 
organism. It is effected according to physical laws, and the 
fracture of the skull takes place in the same way, and with the 
same modifications as would a fracture of any inorganic elastic 
globe. The radiation of the fracture, the effect of the rebound 
of the head from the pavement, and of the brain within the skull, 
cannot be studied by the aid of anatomy or of physiology alone ; 
a third science must be invoked — that of physics. Nor is this 
all. I have spoken of the clear fluid running from the patient's 
ear. To the uninitiated this would seem to be of much less 
importance than the blood which matted his hair. But the 
physician sees in it a symptom of very serious import ; he knows 
that it is a sign of the fracture of a certain portion of the base 
of the skull, and foretells almost certain death. So much he 
knows, or should know, as a fact of clinical experience — that is, 
of the clinical experience of other people ; for he ought to be able 
to interpret this symptom as perfectly in the first case he ever 
saw as in the fiftieth. To understand exactly what this clear 
fluid is, he must, however, interrogate something else than 
clinical experience, for that has interpreted the matter in several 
different ways. The question has been solved by clinical analysis 
of the fluid, which has shown that it does not resemble the serum 
of the blood, which at one time it was supposed to be, but the 
so-called cerebro-spinal fluid, which bathes the brain and spinal 
cord, and which cannot be removed, in even small quantities, 
without the greatest risk to these vital organs. The gravest 
feature in a case of fracture of the skull is interpreted by means 
of the science of chemistry. 

Here, then, are four separate sciences, with entirely distinct 
methods, with which the physician must be to a considerable 
extent acquainted before he can in the least understand the 
condition of the patient in the case we have imagined : anatomy, 
or the science describing the form and relative situation of organs ; 
physiology, or the science of the functions of these organs; 
physics, or the science of the movements of masses; chemistry, 
or the science of the composition of bodies, including the solids 
and fluids of the animal organism. When all these have been 
applied to the problem, the physician is still at the outset of his 



338 Mary Putnam Jacobi 

investigation. It is not enough that he sees, or even correctly 
understands, the condition in which the patient is; he must be 
able to foretell the series of changes which this condition is 
likely to undergo, during its progress towards death or recovery. 
To do this he must be acquainted with a fifth science — pathology; 
a science laboriously elaborated from all the experience, the 
observations, the clinical and post-mortem analyses which 
have been accumulated during the historical period of the race. 
Morbid anatomy is properly a branch of pathology, and nothing 
can be more absurd than the idea that the clinician can busy 
himself with the sick person during life, and leave to a specialist 
in "pathological anatomy" the examination of diseased organs 
after death. You can only properly observe the living sick man 
when you are able, in imagination, to pierce through the outer 
coverings of his body, and watch, step by step, the morbid pro- 
cesses which are creeping onward in the recesses of the organism. 
For this purpose it is essential that a science, really a branch of 
anatomy, but often regarded as distinct, be assiduously cultivat- 
ed. I mean the science of histology. It is only when the 
microscopic structure of the fractured bones and torn mem- 
branes is perfectly known that the physician can understand 
many of the minuter morbid processes whose possibility he 
foresees — as an osteomyelitis, a meningitis, a capillary apoplexy. 
Knowing what exists, and also what is likely to occur, the physi- 
cian is now prepared to intervene to help the patient, and to 
avert danger as far as this may be possible. In other words, 
having applied the arts of diagnosis and prognosis, in accordance 
with the laws of pathology, he is able to apply the art of thera- 
peutics according to the indications furnished, on the one hand 
by surgery, on the other by the science of the properties of drugs. 
He will lift up the depressed fragment of bone by means of a 
trepan; he will apply ice to the head, to keep down hypersemia 
of the meninges; he may possibly give bromide of potassium to 
deaden the activity of the brain when consciousness returns 
and delirium is imminent. 

From this single illustration, you may at once learn several 
peculiarities of the physician's work. In the first place you have 
noticed that the knowledge required is not merely considerable 
in amount but various in kind, and that all these varieties must 
be co-ordinated into a single conception, which we may entitle 



Inaugural Address 339 

knowledge of the condition of the patient. In every step of the 
physician's career he is obUged to perform this work of co-ordina- 
tion; obHged not only to know in detail, but to generalize and 
combine. 

Now the capacity for systematic mental combination is essen- 
tially a cultured capacity, and a capacity whose effective attain- 
ment is a matter of a great deal of difficulty. It is sometimes 
proposed to evade this difficulty by dividing up medicine into a 
great number of small sections or specialties, and encouraging 
every one to devote himself to only one. Even were this done, 
the difficulty in question would not be removed, but only pushed 
back a little. Even when a physician professes to attend only to 
the diseases of a single organ, he still has to do not with one dis- 
ease but with an entire class of diseases. To decide whether one 
of his diseases exists, he must know enough about a good many 
others to be able to exclude them from the diagnosis. Or, if he 
cannot do this, he must get some one else to make the diagnosis 
for him — that is, to take out of his hands the first large part of 
his own work. If we suppose these preliminary questions all 
decided, — and no doubt to remain that disease exists in the organ 
appropriated by this particular specialist — we still can only 
understand this by means of a mass of anatomical, physiological 
and clinical details, out of which he must build up the general 
conception of the case. Thus the mental operation is the same 
in kind for the specialist as for the general practitioner. 

Specialists are needed for original researches, and to develop 
the field of medicine in such a way that it may afterward be 
cultivated by the general practitioner. Auscultation was once a 
specialty, and only a few physicians even pretended to know how 
to use the stethoscope. But today, as you are aware, scarcely 
any one claiming the name of physician would dare to disclaim 
his ability to do so. 

It will always be desirable moreover, that certain persons 
endeavor to acquire unusual skill in some particular directions, 
that they may be called upon occasionally to decide in questions 
of unusual difficulty. But it must be left to the general practi- 
tioner to call in the specialist, as the judge calls an expert into 
court, to assist in making up the decision. The responsibility of 
the decision must always rest with the judge, or the physician, — 
after they have heard all that the experts have to say, and con- 



340 Mary Putnam Jacobi 

trolled their report by means of their own knowledge of the 
subject, and general relations of its parts to each other. 

There is another way in which a specialist may be called in: 
namely, like a chiropodist to attend to some entirely subordinate 
and presumably insignificant detail. Whoever adopts a specialty 
for the sake of narrowing his knowledge, and not in order to 
deepen it, is liable to become a speciaHst of this kind — a mere 
corn doctor; with no valid claim to membership in a liberal pro- 
fession. 

We return therefore to our assertion that it is impossible for a 
real physician to escape the necessity of constantly dealing with 
multiple groups of facts. He cannot therefore be dispensed from 
the necessity of acquiring the mental culture which alone can 
enable him to accomplish this task. To further illustrate my 
meaning, I would point out that there are four successive degrees 
of generalization that may or must be effected by the physician. 
The first degree is that which I have already shown to be involved 
in the very simplest diagnosis of disease in a single organ of the 
body. In a second degree of complexity the physician is obliged 
to consider also the co-existence of a morbid condition in some 
organ, and to ascertain which, if any, are the relations between 
these two. Thus, if the same patient be suffering from dyspepsia 
and endometritis, it is very important to know whether the dys- 
peptic symptoms result from the irritation of the endometritis, 
or whether the endometritis is the final expression of a state of 
denutrition originated by the dyspepsia. If, again, a pregnancy 
complicates the uterine disease, the question of treatment is ren- 
dered more difficult by the risks of interfering with the pregnancy. 

In a third degree of generalization, the physician must rise 
to considerations of the pathogeny of disease, and these are 
inseparable from general philosophic notions to enable him to 
grasp the theory of the matter. Thus, in investigating a case of 
phthisis, the physician will go but a little way who rests with the 
report of subcrepitant rales at the apex of one of the lungs. It is 
imperative that he understand the theory of phthisis, and the 
relations between the theory of Bayle and Laennec, which would 
attribute these rales to ruptured tubercle; the theory of Rind- 
fleisch, which would explain them by the breaking down of 
masses of tissue chronically inflamed; the theory of Buhl, ex- 
plaining the ulceration process by a diphtheritic-like infiltration. 



Inaugural Address 341 

Immediately or remotely, the practical treatment of phthisis is 
moulded by the theory which may have been adopted. 

Similarly, the practical treatment of uterine diseases must 
vary considerably when the theory of menstruation regards this 
process as a congestion, or as a plastic process of growth. 

The highest degree of generalization is that involved in the 
pursuit of original researches. Upon this we will not now stop 
to speak. 

Now, as I have already said, the capacity for generalizing 
is essentially a cultured, an acquired capacity. Whenever it 
seems to be natural, that is, to come without any special training, 
it is always wrong. That is to say, untrained persons of active 
minds, and who are often very ready to generalize, invariably do 
so from too small a number of facts or data. Hence their con- 
clusions are inadequate or absurd. Homoeopathy furnishes an 
excellent illustration of just this kind of generalization. It has 
picked up a superficial resemblance between things; has refused 
to analyze further the real relations of these things, and then 
insists upon having discovered the true theory of their relations. 
Thus Hahnemann gives as an illustration of the way in which 
natural instinct appeals to the law of Similia : the case of a cook 
who, having burned her finger, plunges it into warm water; or, 
the boy whose fingers are frost-bitten, yet who takes care to rub 
them with snow. Now this accidental resemblance between the 
cause of the injury and the treatment explains nothing. A little 
deeper examination shows that, in the first case, the warm water 
is required to relax the distended blood vessels; in the second, 
the cold is needed to restore the circulation gradually and not 
with a rush, which might prove fatal to the tissues. In these 
celebrated examples, an immense fallacy is accepted, by omission 
of the philosophical distinction between two kinds of causes: 
the efficient cause, the burn, which has initiated a train of morbid 
processes; and the proximate cause, that is, the anatomical and 
physiological conditions upon which the symptoms immediately 
depend. 

To train the mind to handle large masses of facts, it must be 
gradually accustomed to work with somewhat smaller masses of 
more accessible facts. This is the reason for that general liter- 
ary education which, in all European schools, is exacted as 
an indispensable preliminary to medical study, and which, 



342 Mary Putnam Jacobi 

in this country, is often considered as superfluous. But it 
can only be so considered by those who have never tried to 
analyze the mental operations involved in the simplest medical 
work. 

Our illustrative case shows that something else is necessary 
also. The senses must be trained as well as the mind. I will 
not now dwell upon the methods for training the senses, but only 
point out two facts. First, that the facility and accuracy with 
which the senses work, is largely in proportion to the amount of 
mental training that guides their operation. You can see, hear 
and feel a hundred fold more when you know before hand exactly 
what is to be felt, or heard, or seen; and when you have an ideal 
standard with which you can compare the results furnished by 
your eye, ear, or finger. In the second place, it is logical and 
much easier to train the senses by means of simple exercises 
before attempting more complex ones. Thus an excellent pre- 
paration for learning how to observe in anatomy, is to pursue 
observations in botany. 

It is now worth while to inquire, since the study of medicine 
is so vast, what proportion of it can possibly be mastered during 
a given term of years: in other words, what we may expect a 
student to know who presents himself for graduation. As the 
foundation of everything, a really complete knowledge of ana- 
tomy is indispensable. It will not do to know that an artery is, 
as the boy said of Abraham, "there or thereabouts." It will not 
do to have a general idea that the nerve centers are divisible into 
a cerebrum or cerebellum, medulla and spinal cord. The ana- 
tomical knowledge that is not precise and accurate is as unavail- 
able for the physician as would be a general idea of the county 
in which a person lived, to the postman charged to deliver a 
letter to him. 

There is another reason for demanding completeness of know- 
ledge in regard to coarse and fine anatomy, and that is, that it is 
so readily forgotten in after practical life, and requires to be so 
constantly revived by fresh reference as wanted. Students are 
apt to think that therefore it never need be fully known at any 
time. This is a great mistake. What has once been firmly 
stamped upon the mind, can easily be revived; what has always 
been vague, will always remain so, unless there take place such a 
radical change in mental habits and methods as we have no great 



Inaugural Address 343 

reason to expect. The science of chemistry, so far as regards its 
relations to medicine, should also be perfectly known at the out- 
set, and can be known because these medical relations of chemis- 
try are at present comparatively so few. Physiology, on the 
other hand, embraces a much wider field — more indefinite and 
more complex details. The knowledge acquired of it during a 
medical curriculum, must be small as compared with the relative 
amount attainable in anatomy and medical chemistry. But 
absolutely, this amount is considerable. It is of the greatest 
importance that the student learn to distinguish the different 
degrees of certainty which exist between the various physiological 
doctrines he hears enunciated. It is in studying them that he is 
first introduced to the peculiar difficulties of the study of medi- 
cine, inherent in its imperfection, in its complexity, and in its 
progressive character. It is impossible to study physiology by 
the memory alone. Even to remember its details requires a 
habit of mental poise — a capacity for criticism and judgment 
which is only acquired by very careful training. In testing the 
candidate therefore, we expect to find, not a complete knowledge 
of physiology, but an accurate knowledge of certain fundamental 
facts, familiarity with accepted methods for both the acquisition 
and application of physiological knowledge, and some trained 
judgment in regard to the grouping of facts known ; finally, sound 
and vivid perceptions of the relations of physiology to medicine, 
and of their constant interdependence upon one another. 

Coming now to medicine proper — what may we expect a grad- 
uating student to know ? It is a mass of knowledge so vast (often 
so confused), so unsystematically grouped together — so largely 
empirical, — so unequal in its development; its acquisition de- 
pends so much upon prolonged clinical experience with personal 
responsibility, that it is really very difficult to define just how 
much may be acquired; how much and what must be expected 
of any one after a given course of study. We can, however, say 
this: First — That the graduate must be thoroughly acquainted 
with the rules of diagnosis, and show his ability to apply them in 
any given case. Second — That he must be acquainted with the 
typical outline of all classical diseases, and thus know the symp- 
toms upon which the diagnosis is based. Then there will be 
nothing to prevent him from diagnosticating even the very first 
case he ever sees of even the rarest disease. Whoever is able to 



344 Mary Putnam Jacobi 

do this; whoever has reached a standpoint from which he can 
scan the entire horizon of medicine, has reached a beginning 
whence nothing need prevent indefinite progress. But unless 
this beginning be reached, the physician is really incapable of 
making the first decision about any one who comes to his office, 
or who calls him to their bedside. A doctor who did not know 
that coryza was one of the symptoms of syphilis, could not safely 
pronounce with positiveness upon the nature of an apparent 
cold in the head. Another, who knew of no eruptive fever but 
measles, would certainly be incompetent to decide that the rash 
in a given case were not scarlatina or small-pox. No young 
physician can be expected to know all about all diseases ; but he 
must be acquainted with at least the existence of all that there is 
to know about. And he must, moreover, have attained sufficient 
mental breadth and grasp to be able to keep the recollection of 
all firmly and clearly before his mind at the same time. Now 
this knowledge is really quite attainable by a curriculum of three 
or four years' duration, if the study be sytematically and intelligi- 
bly pursued. 

The art of therapeutics is much more difficult of acquisition. 
The treatment of a disease involves many more considerations 
than even does its diagnosis; and these are susceptible of much 
greater variety in grouping. Surgical therapeutics, or, as you 
would perhaps call it, operative surgery, is much the simplest, 
and, accordingly, is much farther advanced. The logical method 
would prescribe that before studying the effect of drugs inter- 
nally administered, the pupil should be carefully trained to 
watch the effect of the topical applications, the various manoeuv- 
ers and operations, by which a surgeon deals with cases of external 
pathology. The question that meets us at the outset is, Is it 
really possible for us to produce any definite effect upon the pro- 
cesses of a living organism? This question is at present better 
answered in surgery than in the domain of internal medicine; 
and we should therefore seek for the answer first there. Yet so 
easily are we deluded into believing that whatever is familiar is 
simple, and whatever is unfamiliar is abstruse, that I suppose 
there is not one of you who would not believe that the action of 
a dose of castor oil was much easier to understand than the action 
of a fracture splint; or, again, that any woman physician might 
be expected, in virtue of her sex, to know something of pessaries, 



Inaugural Address 345 

but need not be expected to know anything of orthopoedics, 
although a pessary for the replacement of a dislocated uterus is 
strictly a surgical and, by analogy, at least, an orthopoedic appar- 
atus. What we may expect of a student at graduation is, to 
know the precise physiological action of drugs so far as this is 
known at present ; to know the principal variations in such action 
occasioned by disease; to know the principal indications for the 
use of the drugs ; and, finally, the principal diseases in the course 
of which these indications present themselves. It is unnecessary 
to add that he must know the doses and preparations of these 
same medicines. 

To apply my previous test, I would say that the theoretical 
possession of this amount of knowledge is quite attainable in 
three or four years. The practical availability of it, is attainable 
with such slowness and difficulty, that it would really be desirable 
to pass a law forbidding any young physician from assuming the 
full responsibility of prescribing until, for a year, privately or in 
hospitals, he had practiced under the close supervision of some 
one else. 

The work of co-ordinating multiple facts, which I have said 
was the characteristic work of the physician, must be begun by 
the student in his most elementary attempts at mastering knowl- 
edge. This is the only way in which he can remember the 
immense amount of facts he is expected to know. He must bind 
them firmly into a single bundle, or a definite number of single 
bundles, or they will all fall apart like scattered sticks. 

Every time you learn anything new, you should stop and ask 
yourselves whether you know everything which is implied in that 
knowledge. In studying the anatomy of muscles, you have an 
opportunity of reviving your knowledge of the bones on which 
they are inserted. In studying the course of arteries and the 
distribution of nerves you refresh your recollection of the muscles 
which serve as landmarks to them. In observing any case of 
disease in the college clinics, it should be your self-imposed duty 
to ask yourselves if you know all about the anatomy, histology, 
and physiology of the organs involved in the disease. The con- 
stant, faithful, patient repetition of these inquiries would contin- 
ually render the co-ordination of your various studies more and 
more easy to you ; would train you in the capacity, invaluable in 
a physician, of bringing to bear all your knowledge at any given 



346 Mary Putnam Jacobi 

point, and of turning it to account wherever it was wanted. For 
here is the immense peculiarity of medical knowledge — it must 
all be turned to account. It is tremendously, often terrifically, 
responsible. It is this sense of responsibility which should be 
constantly impelling the medical student to a determination to 
grasp a subject, instead of remaining content to wabble about in 
it. Medical knowledge is not something which can be purchased 
and applied to a patient like a plaster or a poultice ; it is some- 
thing to be handled — like a tool, like an ax — and the effective- 
ness of the handling depends upon the firmness of grip of him 
who holds the instrument. This fact involves a double responsi- 
bility on the part of the teacher. It is not sufficient to expound 
doctrines and convey information; it is essential to train the 
minds of the persons who are expected to profit by it. This 
requires systematic intellectual gymnastics; requires repeated 
practice in all the mental operations which, in after life, the stu- 
dent will ever be called upon to perform. Thus he must be 
taught, he must probably be compelled, not only to remember ap- 
proximately, but accurately; not only to be able to think when 
at leisure and unencumbered, but under strong pressure, and 
perhaps in the midst of the most embarrassing circumstances; 
to express himself, not only in a slovenly, awkward, halting man- 
ner, calculated to make nervous people impatient, and timid 
people alarmed, and arrogant people contemptuous, but in such 
a clear, concise, forcible way as shall always compel attention 
and extort respect from the very midst of hostile criticism. The 
physician, like the soldier, must be trained to act under fire; and 
a training for mere holiday manoeuvers, out of sight of the enemy, 
is lamentably insufficient for the purpose. Human minds are 
not pint-pots, into which we may pour water or milk or wine at 
our option; nor are they often Danaides, which may be quickened 
simply by immersion in a golden rain from heaven. They are 
living organisms which can only use what they have assimilated 
and digested, and wrought into the texture of their inmost 
fibers. 

This vigorous assimilation demands qualities of grit, which 
are as much moral as intellectual. Many moral qualities are 
needed in the practice of medicine to meet the difficulties which, 
though extrinsic to the case considered as an intellectual problem, 
are very important in its practical discussion. The fundamental 



Inaugural Address 347 

difficulty of all lies in the fact that so much depends not only on 
rigid adherence to rules (and there are many more rules for guid- 
ance than you might sometimes suppose), but that nevertheless 
the final arrangement must be left to the individual tact, discre- 
tion, and judgment of the practitioner. The theoretical and 
practical are inextricably intertwined; and the promptness with 
which theories will often be found to effect modifications of prac- 
tice, in itself renders medicine one of the most interesting spheres 
of human existence. Hence in the most abstract reasoning — ^if 
the physician be capable of such — he must always keep his mind 
intently focussed upon the practical purpose towards which it 
must converge. He must see all his reasons, not hovering about 
in the air, liKe bodiless cherubs, around the bed of his patient; 
but embodied in tangible facts and definite actions. He must 
see that his antiseptic fluids actually reach the infected surfaces ; 
he must see that his hot baths are of a given temperature, and 
that his cold applications are renewed as often as they grow 
warm; he must know whether the medicine prescribed has been 
vomited, whether the food has been given at the stated intervals, 
whether the pulse has responded to the stimulant. He must 
know how to enforce his directions, in spite of the reluctance, or 
indifference, or carelessness, or stupidity, or forgetfulness of his 
patients; in spite, moreover, of the interference of friends, who 
invariably try to persuade the sick person to call in another 
doctor. In many cases the physician must almost, as it were, 
carry his patient in his arms, encouraging, urging, consoling, 
inspiring him. To do this he must be capable of sympathy with 
physical suffering, at once delicate and profound. To be effica- 
cious, this sympathy must be fine, and not blubbering; it must 
feel for the patient ten times, a hundred times as much as it 
audibly expresses for him; it must manifest itself in deeds, not 
in words; in indefatigable efforts to accomplish the essential, not 
in rambHng talk about irrelevant trifles, even when, to the sick 
person, these seem to be the most important. 

And at the same time, while treating his patient as though he 
were a personal friend — while, if necessary, risking his life for 
him — the physician must never forget that this same patient is, 
from the nature of things, a possible enemy. A physician pre- 
scribes somewhat as the Spartans under Lycurgus were permitted 
to propose a new law. If the proposition succeeded, the innova- 



348 Mary Putnam Jacobi 

tor was honored immensely; but if it failed he was put to death. 
By the most scrupulous honor and the most conscientious care, 
the physician is bound to justify a claim to the absolute confi- 
dence of his patients; but he must never give them his. He must 
never be off his guard ; never forget that he is the object of inces- 
sant criticism, not only for what he does, but also for what he 
does not do, and for every detail of his way of doing. It is essen- 
tial that in every detail, in every expression, in the entire mental 
atmosphere of the physician, the patient should feel himself in 
the presence of a superior person. He must be conscious that a 
mind warm, vivid, and penetrating is dealing with his case. He 
must be conscious, also, that notwithstanding this personal sym- 
pathy, the physician is studying his case as coolly, impartially, 
abstractly, as if it were a problem in algebra. If he does not do 
so — if, moreover, he fail to solve the problem — sooner or later the 
patient will leave him, perhaps with the best good wishes, but 
still he will leave him, and try his fortune elsewhere. 

You see, therefore, that, in order to be a physician, it is not 
sufficient to have a good memory and be able to pass examina- 
tions. This is indispensable, but much more is required. The 
capacity to examine minutely, yet generalize comprehensively; 
to take large views, yet not overlook the smallest details; to be 
quick to notice, yet slow to speak ; to reason cautiously, yet decide 
promptly; to be at once very cool and very warm; to be tena- 
cious of one's reputation, yet indifferent to careless opinions; to 
be sensitive, yet not touchy ; to be patient in temper, yet capable 
of wrath; to be absolutely honest, yet successfully prudent; to 
be unworldly, yet capable of managing the forces of the world — 
all these mental and moral capacities are necessary to enable a 
physician to study practical medicine, to practice medicine, and 
to build up a practice out of services rendered to a crowd of suf- 
ferers, at once helpless, ignorant, exacting, and capricious. 
Varied as are the mental and moral capacities required for this 
enterprise, they may be all traced back to three, namely : Ability 
to think, character to control, and honor to act from an internal 
instead of an external standard of obligation. When these 
qualities are not possessed, or have been insufficiently developed, 
one of two things happens. Either, in the competitive struggle, 
the ill-prepared physician gets crowded out by more capable 
rivals; or else, he manages to hold his place, but at the expense 



Inaugural Address 349 

of patients, ill-treated by him, and who might have been better 
treated by some one else. 

These patients are the persons who must be kept in view by 
the examining boards, who are licensed with the power to grant 
medical diplomas. This power constitutes a tremendous social 
responsibility. It is quite possible for a medical college to have 
no other function than that of testing candidates. This is the 
case with the University of London. It gives no instruction at 
all, but it grants degrees to all persons, who, having been edu- 
cated elsewhere, are able to pass the scrutiny of its examiners. 
It must always be the principal function of a medical college to 
fix the standard of attainment ; — and to point out what must be 
learned and what must be done to reach this: and thus, finally, 
ascertain as far as possible whether candidates have fulfilled these 
conditions. The college is then able to turn to society and say 
to people entirely helpless to judge for themselves: "Here is a 
person to whom, in perfect confidence, you may entrust your 
most important interests. Upon his knowledge, his skill and 
judgment you may rely as completely as upon that of any one of 
equal professional age in the profession ; and upon his honor, you 
may at once rely absolutely." The responsibility attaching to 
this assertion is so tremendous : the consequences of a false assur- 
ance of confidence may be so various and so disastrous, that in 
comparison with it, sympathy for the disappointment of an un- 
prepared candidate ought to be left entirely out of sight. The 
examining board betrays its social trust the first moment that it 
consents to confer a certificate of capacity upon an incapable 
person. In such a case, it becomes culpable of the same crime, 
for which, after the recent Seewanhaka disaster, the grand jury 
indicted the inspectors to whose false assurances of security that 
terrible disaster was traced. 

This consideration comes up with especial force in regard to 
women medical students. These are still, by the majority of the 
public, regarded as disqualified from the practice of medicine 
merely by reason of their sex. The same reason is not always 
given. It is sometimes alleged that they have too little mental 
capacity; sometimes too little general education; sometimes too 
Uttle physical health; sometimes that their judgment is too 
flighty ; sometimes that their temperament is too excitable ; some- 
times that they have too Uttle self-reliance; sometimes that they 



350 Mary Putnam Jacobi 

have too much self-assurance. But that, whatever be the reason, 
they are intrinsically unable to make, or to be made into, safe 
practitioners. 

When you have assembled together in an institution legally 
chartered and recognized by the State for instruction in medicine ; 
when you find yourselves going through the same exercises as 
those which are being carried on in every other college in the city : 
ultimately brought to a commencement hall, where a band of 
music and a valedictory address seem to imitate to perfection 
those of the best equipped universities, it is not unnatural for you 
to feel as if all this vexed question about women's capacity for the 
profession of medicine had been entirely settled. In reality, 
however, it is not so. It has almost reached the point where it 
can be decided on its real merits, and on the actual results of the 
work done by women as physicians. But it has not quite reached 
even this point, since the preparation afforded to the mass of 
women students is still inferior to that which is attainable, if not 
attained by men. In the meantime, although skepticism has 
become more polite, or veiled, it is still much more wide spread 
than you would probably imagine. Only a few months ago a 
prominent physician of this city expressed the doubt, — in private 
conversation it is true, — whether, in twenty-five years from now, 
any women would be found practicing medicine. A professor 
of Ann Arbor has recently written two letters to a Michigan 
paper to express himself as "decidedly adverse" to the attempt 
of women to practice medicine. A few years ago, one of the 
lady trustees of this college told me that a friend of hers asked 
her why she had anything to do with women doctors, when it 
was notorious that they were all Free Lovers. Last year another 
lady trustee explained the indifference of so many influential 
people to the success of this school, as compared with their 
interest in the Training School for Nurses, on the ground that the 
latter were felt to be a necessity, while a medical school for 
women could only add a poorer class of doctors to an already 
over-crowded profession. There were more doctors turned out 
now every year than could find work to do in the community; 
there was not really any reason for helping to manufacture more. 
When I suggested that some of the women doctors were expected 
to displace a certain number of men, she was perfectly astonished. 
She tacitly took for granted that all the men must first find some- 



Inaugural Address 351 

thing to do: what was left over only, could be taken up by the 
women. 

But now this is the very point at issue. Since society is, 
numerically speaking, already supplied with quite enough doc- 
tors, the only way in which women physicians can possibly gain 
any footing is by displacing a certain number of men. In order 
to do so, they must evidently show qualifications superior to 
those of the physicians whom they displace, and sensibly equal 
to those of the physicians with whom they are to be ranked on an 
equality. 

Now, it is well to at once recognize the fact that a good many 
difficulties stand in the way of both achievements, and these can 
only be surmounted when they have been distinctly recognized 
and systematically provided for. 

It is very difficult for women to make headway against the 
settled opinion of society that they are unfit for final responsi- 
bilities. This opinion not only often hinders their education to 
responsibilities, by preventing people from entrusting them into 
their hands; but it reacts upon their own minds, is liable to make 
them hesitating, undecided, timid, and thus still more to justify 
the social prejudice. It is a common remark, "Women do not 
feel any confidence in women; in an emergency, they must always 
appeal to men." This, because it is the habit of centuries so to 
appeal; because the mass of knowledge, power, and force is still 
overwhelmingly on the masculine side; because, perhaps, the 
mass of such force always will be so distributed, and the women 
in positions of first-class responsibility will always be sufficiently 
in the minority to be deprived of the benefit of traditional influ- 
ence and prestige. The claim to equal confidence as made by a 
woman must be a peculiarly intellectual one, because it must be 
sustained in spite of a conspicuous inferiority of physical strength. 
To produce upon the mind of the average public the same im- 
pression as may be made by a masculine physician, the woman 
must exhibit comparatively more force of mind and character, 
because the force of body is so much less, and in a question of 
forces the impression unconsciously received from physical size 
must be taken largely into account. It is like a watch as com- 
pared with a locomotive; if there be not greater precision of 
action in the one, to balance the imposing massiveness of the 
other, the more delicate instrument must be crushed with con- 



352 Mary Putnam Jacobi 

tempt. Many mental habits of women stand in the way of their 
acquiring this superior precision and surety. These can only be 
acquired by means of repeated tests, and by the prompt rejec- 
tion of all work which does not come up to a given standard. 
But women, as a class, are never habituated to test their work; 
and have an almost irresistible tendency to appeal to some per- 
sonal influence to avert the consequences of its failure. I do not 
wish to make any protest against the habit of appeal to personal 
influence; it is ingrained in the nature of things and of women, 
and when restrained within its proper sphere does a great deal of 
good. But it certainly has a tendency to deteriorate the char- 
acter of women's work, unless they strenuously resist it. 

In the general theory of society, women are not expected to 
achieve anything. This theory is sometimes the reason that they 
are not trained to achieve anything — that their education is so 
flimsy and scrappy; sometimes, again, on account of this theory, 
so much surprise is elicited when they do achieve ever so little, 
that they are flattered into a very dangerous over-estimate of 
their own powers. In this flattery there is often concealed the 
feeling expressed by Dr. Johnson in his celebrated remark about 
a woman preaching: "It is," he said, "like a dog standing on its 
hind legs — it is not well done; but then the wonder is that it is 
done at all." The tendency of women to nestle within a little 
circle of personal friends, and to accept their dictum as the ulti- 
mate law of things, renders them as liable to be spoiled by this 
sort of admiration, as they are liable to be discouraged when they 
do not get any admiration at all. 

The remedy for all this, however, is not hard to find. A 
woman must accustom herself to dispense with the personal 
approbation of the people she knows, as a stimulus for exertion. 
She must learn to work for the sake of the work; she must be 
ready to put into it an amount of labor as would not "pay" if 
estimated merely by what can be seen on the surface; she must 
know how to hold her own standard a good deal higher than that of 
partial friends; she must learn, not only to keep calm under 
blame, but, what is much more difficult for a woman, to bear 
praise unmoved, otherwise she will soon cheapen with the praise. 
The careful self-education of women in all these matters is so 
much the more important, because it is only by means of it that 
they can hope to overcome the more external difficulties by which 



Inaugural Address 353 

they are weighted. It will not do to forget that their health is 
often fragile; that they often begin to study somewhat late in life, 
and when much needful vitality has been exhausted; that they 
are more frequently involved in family responsibilities and com- 
plications. At any rate there is always one two-fold dilemma. 
They are either pecuniarily well off, and then the force of tradi- 
tion tends to keep them from working, because, as it is said, there 
is no occasion for it; or else they work — they study medicine, for 
instance — under such pressure of pecuniary necessity as leaves 
them barely the time or the means for adequate preparation. It 
is comparatively rare that the happy mean exists, where the stu- 
dent possesses just enough money to secure her from want, yet 
not enough to take away the stimulus for exertion. This is 
exactly the amount required. 

The question of marriage again, which complicates every- 
thing else in the life of women, cannot fail to complicate their 
professional life. It does so, whether the marriage exist or does 
not exist, that is, as much for unmarried as for married women. 
In my opinion the increased vigor and vitality accruing to healthy 
women from the bearing and possession of children, a good deal 
more than compensates for the difficulties involved in caring for 
them, when professional duties replace the more usual ones, of 
sewing, cooking, etc. But in this delicate and important matter 
the facility of adjustment will vary in every individual case. 
Many married women will lose all interest in medicine as soon as 
they have children, as many now fail to develop the full needed 
interest precisely because they have no other, and are dispirited 
by isolation from family ties. Many will interrupt their prac- 
tice during the first few years after marriage to resume it later. 
Whatever is done, either with or without marriage, can evidently 
be well done only in proportion as more complete intellectual 
development and more perfect training enables the woman to 
cope with the peculiar difficulties inherent in her destiny. 

Women may be said to have obtained a foothold in medicine 
in modern times on account of the sudden development of gynae- 
cology. It cannot be said that women have contributed much 
towards this development ; but in the treatment of uterine dis- 
eases the desirability of women physicians from motives of 
delicacy, becomes so evident, that a powerful impulse has been 
created in favor of allowing them to practice at least this branch 



354 Mary Putnam Jacobi 

of medicine. From what I can learn, the majority of women 
who study medicine do so with the expectation of at once becom- 
ing specialists: and certainly, the majority of persons who think 
of consulting them, think of them first and foremost, if not ex- 
clusively, in this connection. 

Now, nothing can be more certain than, if women are enabled 
to practice medicine only in this specialty and for this reason of 
delicacy, they must, sooner or later, be again excluded from 
medicine altogether. I say again, because as you know or should 
know, women have at many different times been admitted to the 
privileges of medical studies and practice, but have never gained 
so firm a footing that they were not liable to be displaced. The 
motive of delicacy; the motive of self-support; the motive of 
desire for wider spheres of action, are all perfectly legitimate 
motives, but they are extrinsic to the real reason for the existence 
of any class of practitioners. This reason is, that such a class is 
in possession of knowledge which enables it to understand disease, 
and to cure the sick, and which justifies its members in assuming 
full responsibility. This full responsibility cannot be assumed, 
except after liberal study of the whole field of medicine. If, at 
present, here and there a specialist may arrive at distinction who 
really only knows one thing : he can only do so because the mass 
of the profession know a great deal more. If an entire natural 
class of people devoted themselves exclusively to one thing, 
they would soon not know even that. Instead of obtaining a 
position superior to that of the rest of the profession, they must 
sooner or later sink to an inferior one. In the case of gynaecology 
and women, the practical experiment has been made : the services 
of women have been sought on a large scale exclusively from 
motives of delicacy, and you know in what way. The women 
were merely assistants — employed to make uterine examina- 
tions and report to physicians who were strictly forbidden to 
make such examinations themselves. The women experts 
learned as little of the subject as Milton's daughters did of the 
Latin they read to him without understanding it. The progress 
of science was retarded, and their intervention was finally dis- 
carded as cumbersome. If women will use this specialty, now 
often thrust upon them, as a stepping-stone to general medicine ; 
if they will look upon it as the small end of a wedge, and persist 
in driving it forward to a larger end; then they may assure their 



Inaugural Address 355 

position, and that of their successors, by means of this temporary 
opportunity. But if they do not obtain a foothold on the broad, 
intellectual basis of general medicine; if they content themselves 
with claiming this little corner, they will never really gain a high 
place even there : they will be driven out, little by little, until at 
last the gynaecological wave may pass by, and leave them 
stranded. There may be less liability to uterine diseases; or 
these may be so much more easily foreseen and prevented that 
much less "local treatment" remains to be instituted; or the 
sentiments of delicacy may change. Just imagine what would 
become of a class of physicians now-a-days who had devoted 
themselves exclusively to the treatment of scurvy or of leprosy ! 
Their occupation would be gone with the disappearance of the 
disease; and the boon to humanity would result in ruin to their 
class. 

I wish now, in concluding, to call your attention to a last class 
of difficulties, especially connected with medical schools for 
women. These difficulties all arise out of one fact, namely, that 
there are not as yet a large enough number of women studying 
medicine to support medical schools on a large scale ; and schools 
on a small scale are inadequate, because there is no such thing as 
large or small in medicine. 

During the thirty years which have elapsed since women first 
began to study medicine in America, there have always come for- 
ward a much larger number to claim the right to practice than to 
crave the privilege of being thoroughly well educated. This im- 
fortunate majority has been the cause of immense injustice to the 
higher toned minority, because they have constantly tended to 
drag the conditions of medical education down to the level of 
their capacity, or intention to fulfill them. The competent have 
often been sacrificed, in order that the incompetent might be 
satisfied. A Nemesis never fails to wait upon inefficient intel- 
lectual work. It invariably grows lifeless, dull, uninteresting; it 
finally ceases from sheer inanition. On the contrary, nothing 
more is required to quicken any subject or any occupation into 
the most vigorous life and fertile interest, than that every one 
engaged in it should be inspired with an ardent desire for knowl- 
edge and for high attainment. Whenever people are content to 
do a thing in a slovenly and wanton manner, they very soon get 
to the end of it. But whenever they try to do it as well as it is 



356 Mary Putnam Jacobi 

possible to be done, or try to learn everything about it that any 
one else knows, they find themselves at the beginning of a task 
to which there is no end. They find more to do every day; 
every day, also, they find more power to do it. 

If all the students of this, or any other school, were thoroughly 
imbued with the determination to accomplish the work before 
them in the best possible manner, many of the difficulties inher- 
ent in the comparative smallness of the school would vanish. 
You should learn to look at yourselves as a colony just landed in 
a new country; compelled to found a state in spite of hardship, 
and peril, and danger, and isolation, by means of the vigorous 
and intelligent co-operation of each of its members. I do not 
know that any more instructive reading can be found than the 
history of colonies, a theme with which every American certainly 
should be thoroughly familiar. In studying the various destinies 
of the early settlements of this country, you may gather many 
hints of importance applicable to our present situation. For us, 
also, the sea has been traversed, the landing effected, the howling 
savages, represented by the medical students, temporarily 
repelled. But that is about all which has as yet been done. It 
remains to be seen whether our colony contains in itself the stuff 
out of which the Bay State was built up; or rather those vicious 
and corrupting elements which corroded to destruction so many 
settlements south of the Potomac. And do you know what was 
the one predominating influence that led to such destruction? 
It was that the mass of gentlemanly emigrants, who had not 
learned how to dig, and who were by no means ashamed to beg; 
who had left the mother country, not to seek an opportunity to 
work more, but to work less; to shirk all the work they possibly 
could ; to profit by the industry and courageous patience of their 
companions, in order to share, without due share of labor, the 
revenue accruing from their tobacco and their corn. These are 
not the characters which could have founded Massachusetts and 
laid the corner-stone of that State, where, a century later "em^ 
battled farmers could fire the shot that echoed round the world." 

Theirs is the stuff, these are the characters, this is the austere, 
self-denying, intelligent heroism, which is needed for our enter* 
prise — for this also still deserves to be called heroic. 



SPECIALISM IN MEDICINE ' 

We propose to consider briefly, but critically, the following 
proposition, which, though not distinctly formulated, is, as it 
were, held in solution in many others now current, and may be 
easily precipitated from them. 

At the present day medical science has expanded to such an 
extent that its intelligent cultivation as a whole by any one per- 
son has become impossible. The practice of medicine, therefore, 
to the extent to which it may reach any really high standard of 
excellence, must henceforth be carried on exclusively by special- 
ists.^ 

Thus, the physician, who should, in chimerical imitation of 
Lord Bacon, propose to "take all (medical) knowledge for his 
portion," must, on this theory, be consigned to a limbo of wornout 
inanities. Nevertheless, the most useful functions of special- 
ists are still exercised with tacit reference to the intelligent prac- 
titioner, who is compelled, not indeed to know all about all 
medicine, but to hold the key of admission to any of its branches, 
of which, at any moment, he may have practical need. 

Thus, specialists are justly expected to become the deposi- 
tories of special literature, and to so sift, handle, classify, and 
arrange this, that it become accessible to, and utilizable by the 
general practitioner. By reiterated experience, they are expected 

' Reprinted from the Archives of Medicine, 1882, vol. vii., — Editorial Depart- 
ment. 

» . . . "The fact, the hard and undeniable fact, that all intelligent and 
scientific physicians are quasi-specialists, and must be. In the present develop- 
ment of medical science there is no alternative; a physician must be a quasi- 
specialist, or possess a universal knowledge of a superficial, mostly booky kind, 
— a knowledge wholly insufficient to insure intelligent or successful practice." 
E. C. Seguin, these Archives, April, 1881, p. 186. 

357 



358 Mary Putnam Jacobi 

to acquire an exceptional familiarity with certain types of disease, 
so as to be better able to decide in rare, obscure, or unusually 
difficult cases, when the physician shall call them in. By con- 
tinued application they may tend to indefinite improvement in 
the technique of diagnosis and of treatment. Finally, in regard 
to the state of medical knowledge on any given question at a 
given moment, they may furnish the standards with which the 
knowledge and practice of the general physician must constantly 
be compared and tested. Thus, specialism is largely useful in 
furnishing the exact material with which the general physician 
may make his practical combinations. In his absence, and from 
the languid interest which specialists profess in each other's 
departments, this combination would often not be effected. But 
the problem offered by a sick person is always a problem of com- 
bination. The practical specialist does not analyze, but roughly 
divides this problem according to considerations frequently 
artificial. The scientific specialist abstracts phenomena com- 
pletely; studies separately, anatomical, physiological, chemical, 
pathological conditions. It is the ideal business of the physician 
to take conditions which science has abstracted for the purpose 
of thought, and to recombine them for the purposes of life. In 
the absence of the physician there would be no one to do this; 
with every new deterioration of the ideal character of the general 
physician, this work of combination is less and less well done. 
As a consequence, every sick person who can pay for it begins to 
expect to divide up his body among a cluster of "eminent special- 
ists" before any positive diagnosis of his case can be reached. 

Notwithstanding the inconvenience and expense of this pro- 
cedure, it tends to gain in popularity on account of the simplicity 
and apparent common-sense of its theory. The laity are very 
ready to infer not only that specialism is good, but that the more 
of it the better. If the physician who treats six diseases is 
necessarily superior to him who is willing to manage sixty, then 
he who confines himself to one must be the best of all. Hence 
the popularity of the pile doctor, and the cancer doctor, et hoc 
genus omne. 

The great principle of unity in diversity, whose research is 
the problem of philosophy, is also the animating principle of 
philosophical medicine. But this cannot be appreciated by 
persons who are neither physicians nor philosophers. 



Specialism in Medicine 359 

The complete theory of practical specialism admits that a 
man may be a shining light in a subject "which interests him," 
yet a perfect idiot in another of equal importance to the patient. 
Now, the initial problem of diagnosis is the decision of the de- 
partment to which the case belongs; and, on the above theory, 
the fate of the patient must be a matter of chance. If his case 
happen to fall on the competent side of the doctor he consults, 
well and good; but if not, it must fail of recognition. No fixed 
value can be attached to any symptom, when it is remembered 
that the lines of disease intersect each other in every direction. 

Thus, does a young girl fall into a melancholy? The question 
would arise : Shall she be at once entrusted to the gynecologist on 
the suspicion of uterine disease, or to a hasmatologist for chloro- 
anaemia, or to the superintendent of an asylum as a case of in- 
cipient insanity, or to a friend of the family to bring about a 
thwarted project of marriage? If a woman has a pain in her 
back, how many physicians must be consulted before deciding 
whether this be due to muscular denutrition, or to uterine dis- 
placement, or to chronic nephritis, or incipient myelitis, or to 
commencing caries of the vertebra, or merely to hysteria? When 
a typhoid fever simulates general tuberculosis, or the reverse, 
should the diagnosis be made by the heart and lung specialist, 
or by the fever doctor ? When a man falls down in an apoplexy, 
does his case belong to the neurologist, or to the specialist in 
diseases of the heart whence an embolus may have been carried, 
or to the practitioner devoted to gout and atheroma? Shall a 
children's doctor decline to perform an urgent tracheotomy 
because he is not a surgeon ? or shall a physician tolerate irrepar- 
able delay in reducing a dislocation for the same reason? ^ 

It is sometimes said that the conscientious specialist will be 
sufficiently trained in general pathology to recognize when a sub- 
ject lies beyond his domain, and he will then, "in justice to his 
patient," hand him over to one of his own "eminent colleagues." 

Dr. Barnes, who, of all gynecological specialists, most fre- 
quently deprecates specialism, thus illustrates the case: "A 
woman comes to him complaining of pruritus. Much to her 
astonishment, he examines her urine, because he retains enough 

' We have within a few weeks seen two cases of irreparable injury caused by 
just this fact, and by the prolonged application of poultices instead of prompt 
operative interference. 



36o Mary Putnam Jacobi 

knowledge of general pathology to know that pruritus may indi- 
cate diabetes. Finding sugar, he at once resigns the case and 
sends her elsewhere." This illustration represents a class of cases 
which do often occur, and where the specialist is really both com- 
petent and conscientious the case may be managed without 
further inconvenience to the patient than that of a double con- 
sultation. But — and this is a practical inconvenience of per- 
haps a low order for mention here — there is certainly no more, 
but rather less, guarantee for the honor of a specialist than of a 
general practitioner. The last is expected to take charge of 
the patient whatever may prove to be the matter with him. His 
interest, therefore, in ascertaining the exact state of things is 
identical with that of the patient. But the specialist knows 
he will only be entrusted with the case if he can prove that it 
falls within the limits of his own specialty. He is therefore 
always under a strong temptation to "make out a case," and for 
this purpose, if necessary, to rather avoid than to seek close 
scrutiny of the surroundings. 

We hasten to recognize the fact that there are many specialists 
of honor as high and unsullied as could be claimed for the most 
upright physician. But we think the existence of the special 
temptation we have referred to can hardly be doubted, nor that 
this temptation is by no means always resisted. Apart from this 
purely practical consideration, it is to be remembered that such 
definite grounds of classification are more often absent than pres- 
ent ; the specialist confronts the theoretical difficulty of not being 
quite sure what he is to exclude. 

Another important inconvenience in the tendency to universal 
specialism is that the beginnings of disease are so often likely to 
escape detection. To consult a specialist, the patient will first 
wait until he is pretty sure he has the specialist's disease; thus, he 
must wait until this is rather well developed. Thus, too often 
no attempt is made to treat a chronic disease until it has become 
almost incurable, nor to make the precise diagnosis of an acute 
disorder until it has nearly killed the patient. 

But the collapse into inefficiency of a general practitioner is 
not an adequate basis upon which to develop an accomplished 
specialist. Instead of either the one or the other, we obtain a 
confused, vague, cheerfully optimistic "family doctor," who re- 
lieves himself of responsibility for one organ in his patient's body 



specialism in Medicine 361 

after another on the ground that it belongs to some "specialist," 
who, as long as symptoms are not importunate, declares that 
they will "pass away of themselves," — instinctively dreading the 
recognition of their importance as the signal for a surrender of 
the case. Thus, epitheliomas are allowed to extend until they are 
ineradicable, and chronic pneumonia to eat out caverns in lung 
tissue unsuspected, and the child to limp from habit into a sup- 
purating coxitis, and the melancholic to commit suicide while 
sent on a journey for change of scene. 

In addition to the functions which may be unquestionably 
fulfilled by specialists with great advantage to the community at 
large, other claims are often advanced of, we believe, less validity. 
Thus, it is said: 

1. That to specialists alone, or chiefly, is due not only the 
improvement of technique, but the discovery of the fundamental 
ideas which change the face of science. 

2. That specialists are habitually engaged in life-long re- 
searches in the subjects of their specialty. 

3. That, thus, the patients of a specialist must profit much 
more by his intellectual activity than can the patients of a general 
practitioner by his. 

4. That, whereas a general practitioner can only have at best 
a partial acquaintance with the many diseases he treats, the 
specialist, in virtue of his wise limitation of observation, can 
know all about his. 

5. Finally, that the establishment of specialities alone per- 
mits the accumulation of clinical material in definite and avail- 
able masses. 

The first claim might be contested a priori from the considera- 
tion of the evident necessities of the case. No idea in a specialty 
can be as fundamental or as original as that on which the spe- 
cialty is founded, and this evidently must have been suggested 
by a non-specialist. Laennec was not a specialist when he 
practically discovered the principles of auscultation; his pro- 
longed special application afterward was devoted to the consoli- 
dation and simplification and detailed establishment of his theory. 
Helmholtz was no oculist when he invented the ophthalmoscope ; 
even his treatise on optics was written later. Czermak was not 
a specialist when he invented the laryngoscope. Orthopedics, 
perhaps, dates its modern impulse from the researches in locomo- 



362 Mary Putnam Jacob! 

tion of the brothers Weber, who were physiologists. The prin- 
ciple of counter-irritation in joint diseases was established by 
Pott, a general surgeon of London; the still more important 
principle of rest was elaborated by Bonnet, a general surgeon of 
Lyon. The effective introduction into orthopedic surgery of 
resection was made by Sayre before he became an orthopedist. 
In gynecology the capital operation of ovariotomy was initiated, 
as is well known, by McDowell, a general surgeon, having been 
originally suggested by Hunter, than whom none of the great 
physicians of the eighteenth century was less of a specialist. It 
was the great surgeon Belpeau, and the author of a treatise on 
neuralgia, Valleix, who first called attention to uterine flexions 
and suggested pessaries. Dr. Sims had hardly become a special- 
ist when he invented his speculum and contrived his operation 
for vesico-vaginal fistula, achievements which his long career has 
never enabled him to excel. 

Modem dermatology is based upon anatomical researches, 
which may be, and often are, carried on by histologists who do not 
practise medicine at all, — hence could not be called practising 
specialists. The clinical researches of the French school, being 
conducted according to the theory of diathesis, were not and 
could not be made by physicians limited in clinical observations 
of skin diseases. The theory may be discarded ; but the results 
of the impulse given under its influence remain. In neurology 
clinical specialism was first suggested by anatomy, and later by 
physiology. In no practical specialty is modem clinical obser- 
vation kept more closely to these two fundamental sciences than 
in this. The principal facts and ideas have come from anatom- 
ists or physiologists, or from non-specialists, who have also 
furnished the chief clinical groupings. Bell's discovery of the 
double function of the roots of nerves was made in his capacity 
of anatomist; his discovery of external facial paralysis, in his 
capacity of general practitioner. Marshall Hall, Brodie, Aber- 
crombie, Calmeil — even Broussais, with his "De 1' Irritation 
et de la Folic," — and a host of others, who were the early pioneers 
in this century in the study of nervous diseases, were not special- 
ists, since it was indeed at that time not possible to be one. 
Nevertheless, many of their observations remain of permanent 
and fundamental value. The most eminent physiologists, who 
have contributed to knowledge of nervous diseases far more 



specialism in Medicine 363 

than have simple clinicians, have not been specialists in the 
physiology of the nervous system. Magendie, who divides with 
Bell the honor of the discoveries in the spinal roots of nerves, 
wrote two volumes on the "Physics of the Animal Organism." 
Bernard is as distinguished for his composite researches in 
diabetes (to go no further) as for those on the vaso-motor system. 
Schiff, who distinguished the paths in the cord for different 
sensory impressions, has written a treatise on digestion. Neither 
Tiirck nor Bouchard were practical specialists when they estab- 
lished the fact of descending degenerations; nor was Waller when 
he made the famous experiment which has served to explain 
these morbid processes. Brown-Sequard's researches in epilepsy 
were made at the very beginning of his career, and not when 
he had become a specialist. The clinical groups of locomotor 
ataxia and pseudo-hypertrophic paralysis were established by 
Duchenne, whose specialty was not nervous diseases, but faradic 
electricity, and originally, in its application to orthopedics. Ex- 
ophthalmic goitre has been discovered by Basedow, a sagacious 
general practitioner; and the same is true of Addison's disease. 
Gubler, the first to point out crossed paralysis, was never a 
specialist; indeed, his essay on the hepatic lesions of hereditary 
syphilis is as famous as any that he has written. Sir William 
Gull's and Stanley's observations on paraplegia from renal cal- 
culus initiated research into "reflex paraplegia." No one could 
suppose them to be specialists. 

Another class of examples is offered by writers who had 
become specially identified with neurological practice before 
publishing the treatises now recognized as authoritative, yet 
who, before this, had achieved distinction in other directions. 
Thus, Griesinger's now classical work on psychiatry was pre- 
ceded by an only less famous treatise on infectious diseases. 
Ley den, before writing two volumes on diseases of the spinal 
cord, had published a valuable monograph on icterus. Noth- 
nagel's admirable clinical contributions to the problem of cerebral 
localization, and his less admirable experiments on the brain, 
cannot efface recollection of his hand-book of therapeutics — on 
the whole, the most valuable extant on the subject. Charcot 
began his studies in neurology by general studies on the diseases 
of old age. He was stimulated by the practice of no specialty, 
but simply utilized the neglected pathological materials accumu- 



364 Mary Putnam Jacobi 

lating in oblivion at the Salp^tri^re. Only recently, moreover, 
Charcot has published a series of lectures on the pathology of the 
liver and of the kidney; and his description and analysis of the 
lesions of broncho-pneumonia have thrown new light on a sub- 
ject supposed to have become hackneyed. 

These examples, selected at random, do not of course exclude 
the clinical discoveries or inventions which have been made by 
practising specialists, and in a manner which indicates that they 
were the direct outgrowth of their special clinical experience. In 
neurology, Westphal's discovery of the tendon reflex symptom; 
in gynecology, Emmet's operation for lacerated cervix, are typical 
examples of this class. The fact that Hitzig, whose discoveries 
on the motor irritability of the cortex have had such an enormous 
influence, has been for a long time the superintendent of an 
insane asylum, is not an example of the influence of practical 
specialism. His researches were purely physiological, and were 
suggested by physiological considerations, which clinical obser- 
vations might confirm, but did not suffice to originate. 

We think the cases quoted are sufficient to demonstrate that 
indefinite repetition of clinical experience is never of itself suf- 
ficient to suggest new ideas; that a life-long specialism in no wise 
predisposes to discoveries, and still less is essential to their 
achievement ; that in a large number of cases, if not the majority, 
the consecration to a specialty has followed, and not preceded, the 
discovery which has achieved the reputation of the specialist, 
and has fascinated him, perhaps for ever, with the subject. But 
it is always genius which invents; special application can only 
improve; it then remains for culture to appropriate. 

Our limits compel us to be brief with the three remaining 
propositions. In regard to the second claim, namely, the life- 
long researches supposed to be carried on by practising special- 
ists, we would call attention to a fact usually overlooked. It is 
that for every mind, in regard to every subject it studies, there 
exists a saturation point of suggestiveness, which is not exceeded 
by enforced prolongations of attention. It is very useful for a 
person to pursue a subject, so long as it continues to yield him 
ideas; very useful to practise a technique, until it be sufficiently 
mastered to meet all difficulties of execution. But afterward 
there remains no intellectual advantage in persistent adherence 
to the same line of thought. There are personal, often pecuniary 



Specialism in Medicine 365 

advantages; there is profit gained from an acquired reputation 
and previous labors. But this, however legitimate, is a very 
different thing from continued progress in science, or indefinite 
improvement in care-taking of patients, such as is generally 
assumed. 

Again, the practical specialist does not, fortunately, often 
select only one disease, but one organ, or presumably associated 
group of organs. Now cases of the same disease in different 
organs are apt to present many more points of resemblance than 
do cases of different diseases in the same organ. There is much 
more analogy between uterine cancer and epithelioma of the lip 
than between uterine cancer and uterine flexions. The study of 
the pelvic curves throws no light on embryology, although both 
subjects are assigned to the obstetrician. Uraemic peritonitis is 
better understood by study of septic peritonitis than of renal 
calculus. Epilepsy has much less resemblance to the systemic 
forms of myelitis than to the eclampsia induced by acute hemor- 
rhages, and so on. 

Practical specialism only enforces attention to clinical obser- 
vation : analysis of this, on the basis of any special science, is as 
optional with the specialist as with the general practitioner, and 
as liable to be neglected. Many good specialists are purely 
clinicians; many others, really distinguished in some branch of 
science connected with special disease, are quite innocent of 
others. Perhaps from few experts in consultation would we ex- 
pect familiarity with such a monograph as Bert's on respiration, 
or with the complex laws on diffusion of gases. It would not be 
difficult to name neurologists distinguished in experimentation, 
but who have never mounted a section of nerve tissue for the 
microscope. It would not be impossible to cite skillful surgeons, 
most ingenious in mechanical contrivance, who are unaware of 
the pathological anatomy of the tissues they divide or remove. 

Great as are the difficulties arising from the great increase in 
the mass of knowledge, there are many palliations. The per- 
fected machinery for sifting, analyzing, classifying, and sorting 
this knowledge, renders it ten times as accessible and compre- 
hensible as was formerly one tenth part as much. Many gen- 
eral principles have been established, which link together, in 
lucid unity, hosts of details, once unconnected, unintelligible, 
and hence most difficult to remember. The classical body of 



366 Mary Putnam Jacobi 

doctrine in medicine, whose possession is essential to the practice 
of medicine {secundum artem), is really more accessible to-day 
than at epochs when some narrow system professed to crush it 
into a portable nutshell. Finally, the advance of science and of 
scientific method exacts, that who would claim to contribute to 
further progress must concentrate himself much within the limits 
of any conventional specialty. No one disease, no one organ 
may be compassed by a single observer: happy he who may, by 
laborious research, contribute to the solid establishment of a 
single detail of the truth. For such work it is, theoretically at 
least, as easy for the general, as for the special physician to with- 
draw a certain portion of his attention from practice. Neither 
can hope that his research can benefit more than a small propor- 
tion, if any, of his own patients. The one must, as much as the 
other, depend on the collaboration and unconscious cooperation 
of a thousand workers. For both, are needed not only clinical 
observations, but the mental ability to utilize observations, — 
a mental training in the art of handling large masses of ideas. 
For both, if we may judge from European examples, the personal 
experience to be gained in private practice is insufficient ; to both, 
should classified hospitals be open as the true field for pathological 
study. 



SHALL WOMEN PRACTICE MEDICINE? ^ 

The continually renewed discussion, on the part of society, 
concerning the sphere, capacities, rights, functions, duties, and 
allowable occupations of women may well seem, from some 
points of view, rather ridiculous. We may justly ask why 
women require so much more discussion and preachment than 
men; and may even decide that the argument is largely super- 
fluous, and the sermon often impertinent. 

Further consideration, however, discloses several grounds of 
justification for this social habit, from which, in any case, it is 
quite impossible to escape. In the first place, women, as the 
most malleable part of the social organism, are destined to re- 
ceive the first, and also the most lasting, impress of prevailing 
social opinions. They transmit — the phrase is becoming classi- 
cal — the organized experience of the race. The least change in 
such experience affects them especially, and hence they must bear 
the special brunt of the criticism upon it. 

In regard to the particular subject we propose briefly to con- 
sider, social opinion is of very real importance. Success in a 
professional career necessarily depends, to a large extent, on the 
taste of the community. There must be a readiness to consult 
women physicians; a willingness to educate them; a sufficiently 
wide-spread desire on their part to be so educated. If the social 
prejudice be very strong, no young woman will dare express the 
wish to study medicine. Should the vagrant fancy arise, it will 
be promptly checked, as something eminently improper, — like 
going on the stage, or dancing on the tight-rope at a circus. That 
considerable numbers of women do now study medicine and sup- 
port themselves by its practice, is itself a proof that the prejudice 
of thirty years ago has somewhat abated. Women are admitted, 

' Reprinted from the North American Review, January, 1882. 

367 



368 Mary Putnam Jacobi 

in America, to the State universities of Michigan and of Cali- 
fornia, and sustain, moreover, three separate schools: one in 
Philadelphia, one in New York, one — the youngest — in Chicago. 
In Europe, they study at the universities of Paris, Zurich, Berne, 
Upsala, Ley den; have a separate school at St. Petersburg, and 
are admitted to examinations for degrees at the University of 
London, and also at Dublin. They are members of various 
medical societies, contribute to various medical journals, conduct 
hospitals, perform surgical operations, build up practice, and in 
other ways seem to conduct themselves and to be treated like 
other members of the medical profession. 

Yet discussion still continues, and although the once contin- 
uous opposition has become intermittent, its crises are perhaps 
rendered more noticeable on that very account. The centennial 
meeting of the Massachusetts Medical Society was agitated by a 
renewal of the controversy concerning the admission of women 
physicians. Their cause found vigorous champions, but was 
defeated, when an equally vigorous opposition supported the 
majesty of precedent, by the tactics of parliamentary maneuver- 
ing. The siege at the gates of Harvard, destined to be as mem- 
orable, we believe, as that formerly laid against Thebes, is still 
maintained. The echoes of the fierce battle waged in the Uni- 
versity of London have scarcely died away; a few years ago, 
the Society of German Naturalists, meeting at Berlin, voted to 
"purge itself of the presence of women"; and only last summer, 
public attention was called to the formal exclusion of women 
from the International Medical Congress, at its first meeting 
held in England. The measure, it is said, was taken in obedience 
to the wishes of the Queen, and certainly to those of the court 
physician. Sir William Jenner. 

All innovations excite opposition. But it is difficult to ac- 
count for the peculiar bitterness of the opposition which has 
been manifested to the admission of women to medicine, when it 
is remembered that this admission is no innovation at all. Wo- 
men practiced freely in medicine so long as the practice of medi- 
cine was free, and entrance upon it was decided merely by natural 
taste for dealing with the sick and ministering to their infirmities. 
When, however, instruction in medicine began to be systema- 
tized, when universities took charge of it, and legal standards 
of qualification were established, women were excluded, because, 



Shall Women Practice Medicine ? 369 

at the time, no one thought of them as either able or wilHng to 
submit to the new conditions imposed. The monastic discipHne 
out of which universities had emerged still molded their etiquette 
sufficiently to render them inaccessible to women. The women 
themselves do not appear to have thought of presenting them- 
selves as candidates for a university education. Thus, in the 
onward current of progress, the women physicians of the Middle 
Ages, or, in France at least, of all the centuries preceding the 
Revolution, were dropped on the bank. Women are now merely 
endeavoring to reenter the stream, by adapting themselves, 
whenever they are allowed to do so, to the changed conditions 
of things. 

In this effort, the most serious obstacles to be encountered 
are not always the most real ones. In this, as in everything that 
women do, the question of capacity is often outranked by the 
question of taste. Whether woman, with all her organic imper- 
fections on her head, can be theoretically supposed capable of the 
study and practice of medicine; whether, which is quite a dif- 
ferent question, there actually exist any number of women whose 
capacity in this direction has been fairly tested and demonstrated, 
— these are interesting subjects of inquiry. But the most com- 
pletely affirmative answer to such inquiry might still leave un- 
settled a question of much more importance for that large class 
of people whose convictions and actions are under the permanent 
domination of their tastes. These ask not, "Is she capable?" 
but, "Is this fearfully capable person nice?" Will she upset our 
ideal of womanhood, and maidenhood, and the social relations of 
the sexes? Can a woman physician be lovable; can she marry; 
can she have children ; will she take care of them ? If she cannot, 
what is she? "Qu'est ce qu'unefemme," said a French journalist 
in this connection, "qui n'est ni Spouse ni mere?" "God," de- 
clared a Boston physician, well versed in the counsels of Provi- 
dence, "never intended women to practice medicine." Hence 
the inference that piety, if nothing else, demanded the exclusion 
of women from the Massachusetts Medical Society. 

It is from the peculiarity of the conditions involved, that the 
handful of women now engaged in the practice of medicine may 
be considered in any way to affect or endanger existing arrange- 
ments or social ideals. Thousands of women, from manifold 
causes quite extraneous to medicine, remain celibates all their 



370 Mary Putnam Jacobi 

lives; yet no one reproaches them for refusing the duties of wife 
and mother. Thousands of women earn their living by non- 
domestic labor; one profession, that of public teaching, practically 
thrown open to women only during the last half-century, is al- 
ready thronged by them. Yet no one feels that the foundations 
of society are therefore liable to be overthrown. What is it in 
the profession of medicine which excites, at present, such different 
feeling and such bitter prejudice? 

There are several things. In the first place, the profession 
of medicine has always been subjected to popular misconcep- 
tions, and the odium due to these is necessarily shared by the 
women who aspire to be physicians. Again, by a social fiction, 
it is assumed that the usual employments now sought by women 
are to be filled by them only while waiting for marriage, or as a 
resource in widowhood or desertion. Even such professional 
work as teaching is expected to be laid aside after a few years, 
and there is much, at least in the primary grades of teaching, to 
make such interruption rather desirable. But the profession of 
medicine must be chosen deliberately, and not at hap-hazard; 
from a strong and genuine taste, and not from the mere press- 
ure of economic necessity; it must be seriously prepared for in 
youth; must be entered upon at the age at which at present 
many women marry; does not yield its best returns until full 
maturity has been reached; must be adopted, therefore, if at all, 
for a life-time. Hence is required either an accidental celibacy 
or a deliberate renunciation of marriage for the sake of medicine, 
such as is not dreamed of in regard to any other work; or else 
such an adjustment of domestic claims as shall render them and 
the practice of medicine by married women mutually compatible. 

But further, apart from the special odium attaching to medi- 
cal knowledge, the assumption of capacity on the part of women 
for any knowledge which leads to first-class responsibilities 
offends the average social ideal. Again: The idea of mental 
training as a means of developing force is rather new to the 
world in any aspect. It is practically almost unthought of in 
regard to women, who are habitually estimated by the measure 
of their native, untrained capacities. This is seen to be inade- 
quate for the responsibilities of medical practice. 

To consider a little in detail the foregoing topics. The as- 
sertion that medicine and physicians are permanently and pro- 



Shall Women Practice Medicine? 371 

foundly misunderstood by the public may not at once be accept- 
ed. Yet, it is certain that, despite the familiarity of his presence 
and appearance, the laity know less about the doctor than about 
any one else with whom they have to do. They cannot under- 
stand why he wants to dissect, or to "vivisect," or to make post- 
mortem examinations; why he stickles for a punctilious etiquette; 
why he is fascinated by repulsive objects; why he can find fathom- 
less mysteries in the commonplace miseries which they have to 
endure; and how, by any process of reasoning, the recondite 
connection between these mysteries can be detected and made 
clear. The handling of familiar things in an unfamiliar way is 
a process inevitably bewildering to the uninitiated spectator. 
There is something uncanny about it. Moreover, the human 
body has ever been esteemed sacred. From the Egyptian em- 
balmer down, those who have dared to intrude upon its mysteries 
have been branded as profane. When, from the pressure of 
evident necessity, the profanity has been tolerated, the tolera- 
tion has only half-repressed a shuddering horror at the sacrilege. 
The violent popular excitement recently aroused in fox-hunting 
England against physiological experiments — ^with such effect 
that they have been practically forbidden by legislation — recalls 
the still more violent agitations in the last century against 
"body snatching," and the legislative repressions of anatomical 
studies. Mr. Tennyson, in one of his latest poems, draws a 
caricature of the most humane of professions in the person of 
a "red-bearded" student from "the hellish schools of France." 
In 1794, Mrs. Shelley, in her romance of "Frankenstein," stig- 
matized the sublime search after the origins of life as "dabbling 
in the filthy secrets of the grave." The same sentiment really 
animates the modern poet-laureate and the wife of the elder poet; 
although in recent times exquisite experiments have somewhat 
redeemed the theme of the spontaneous generation of life from 
the realm of "filthiness," and the " anti- vivisection " prejudice 
drapes itself in the pretext of philanthropy. But at bottom the 
feeling is identical. Life is a mystery ; the attempt to penetrate 
mysteries is a sacrilege; and terror of the awful, unknown conse- 
quences of sacrilege is quite sufficient to overpower the reason- 
able apprehension about intrusting the care of sick bodies to 
persons who have been forbidden to learn anything about them. 
Now, the introduction of women into a sphere regarded as at 



372 Mary Putnam Jacob! 

once dirty, horrid, and irreverent certainly shocks many of the 
"finest sensibilities of our nature." The feminine university 
founded by Tennyson's lovely Princess had, among all its schools, 
"not one anatomic." She could not bear 

" txD ape 

The monstrous male, who carves the living hound"; 

and only in the spirit of the sublimest self-sacrifice could she, 
fearing casualty, be induced, 

" through many a weary month. 

To learn the craft of healing." 

The poet does not seem to doubt her capacity for mastering this 
wearisome business, but evidently feels that the Princess would 
have been alienated from poetic sympathies had she found the 
task other than repulsive — had she delighted and gloried in it 
as a real physician must do. In this estimate, he strikes the key- 
note of average popular sentiment. 

That the study of the mechanism of the human body is not 
mere dirty work, but one of the most sublime occupations; that 
mysteries are not sacred, but embarrassing masses of ignorance 
destined to be dispelled; that the sensuous disgust attendant on 
anatomical and physiological research can be, and is, completely 
consumed in the divine flame of an idea; that human life is 
more precious and more deserving of reverence than any of the 
accidents, physical or social, by which it is environed — these con- 
victions have been steadily pressed against the inert minds of 
the unreasoning multitude, until they have at last secured for 
themselves toleration, if not acceptance. The odium attaching 
to the study of medicine by women must be overcome by similar 
means. The charge of ' ' unsexing themselves ' ' by the acquisition 
of the particular kind of knowledge required in medicine is, after 
all, less formidable than that of "dehumanizing themselves," 
which, in one form or another, has so often been brought against 
men for the same thing. With those whose beliefs are not a 
matter of reason but of habit, the mere repetition of a fact until 
it becomes habitual is sufficient to insure acquiescence. This cir- 
cumstance goes far to compensate the inconvenience of the preju- 
dice engendered by the mere fact of unfamiliarity. 

Touching closely upon the universal prejudice which is prim- 
itively rooted in the terror of sacrilege, comes another, which, at 



Shall Women Practice Medicine ? 373 

the present day, is held almost exclusively in regard to women. 
It is often said that the work of practicing medicine is necessarily 
so coarse and disagreeable, that none but coarse and disagree- 
able people are naturally fitted for it; or, if others engage in it, 
they must inevitably deteriorate to an inferior personal and social 
level. 

Now, the people who advance these statements have often 
themselves been sick — have had, therefore, frequent personal 
intercourse with physicians. It is, therefore, pertinent to inquire 
whether these delicate ones have always found their own phy- 
sicians to have been rough-shod brutes, or whether they consider 
that the task of ministering to their infirmities in any way 
necessitates coarseness and harshness ? The tacit answer to this 
inquiry is, we believe, that refined people would never do any- 
thing so eccentric as to consult a woman physician. She must 
perforce "go about among all sorts of people," pick up her prac- 
tice where she can, and the process of "going about" is often 
alluded to as if it implied carrying a revolver, or seeking the 
escort of a policeman. 

Of all the social bewilderments with which this question is be- 
fogged, this is, perhaps, at once the most ridiculous and the most 
exasperating. It is impossible to imagine a sphere in human 
life, with the exception, perhaps, of the artistic, in which delicacy 
• — mental, moral, and even physical — is more essential than in 
that of the physician. The preservation of decorum, the main- 
tainance of suitable reserves, the just balance of rights, the quick 
perception of feelings, all these are the natural correlatives of the 
deft physical touch, of the intellectual subtlety, which should, and 
which does, characterize a true physician. What is there in all 
this incompatible with the classical, not to say conventional, ideal 
of feminine character? 

There is another consideration more excusably overlooked. 
It is impossible to be a physician on the basis of personal sym- 
pathies alone. If the interest in the disease be not habitually 
greater than the interest in the patient, the patient will not 
profit, but suffer. He may gain a nurse, but he loses a physician. 
Now disease, even more than death, tends to level distinctions. 
It diminishes the social value of those who have any ; but, on the 
other hand, it invests with an otherwise unattainable interest 
those who are quite lacking in social charm — the stupid, the 



374 Mary Putnam Jacobi 

vulgar, and even the vicious. The physician is, indeed, the only 
person who can "go about among all sorts of people," unbored 
and uncontaminated. When the priest does the same thing, it 
is because, as far as may be possible, he imitates the bearing of 
the physician. 

The only possible excuse for this wide-spread assumption, 
that women physicians must be inferior to men in personal re- 
finement and social culture, may be found in the conditions under 
which women have hitherto been obliged to study medicine. 
The obloquy heaped upon women students of medicine has been 
so great that many women of refinement have been repelled 
from a pursuit to which their natural taste inclined them. Con- 
versely, many women have entered upon it without taste or 
understanding, but merely attracted by the flavor of notoriety 
and the enjoyment of something slightly turbulent and very 
eccentric. Not these ignorant women, but society, are to blame 
for the opportunity accorded to put forth their absurd preten- 
sions. A Nemesis waits upon the rejection of just demands. 
The refusal to admit to a disciplined education and to submit 
to suitable tests the women who were really fitted for both, has 
merely resulted in the rather extensive education of the unfit; 
and this has often been carried on in the very least suitable 
manner which human ingenuity could devise for the purpose. 

Considerations of delicacy have been urged, as is well known, 
in a special manner, both for and against the admission of women 
to medicine. On the one hand, the association of women with 
male students in professional schools and medical societies, has 
been denounced as an indelicacy which rather more than borders 
upon immorality. On the other hand, the treatment of female 
patients by male physicians — especially in a certain class of 
diseases — is shown to involve a straining of delicacy which cannot 
but be most undesirable, even when it is submitted to as inevit- 
able. In the most populous quarter of the globe, in all the coun- 
tries of Asia, it is known that such submission is not considered 
inevitable — is, indeed, not allowed. The alternative is invari- 
ably accepted of leaving the female half of the community entirely 
unprovided with medical attendance for any disease whatever.* 

' To THE Editor of the Pall Mall Gazette. 

Sir: The October number of the "Indian Female Evangelist" supplies 
an interesting piece of evidence on the disputed point as to whether properly 



Shall Women Practice Medicine ? 375 

No hard names which have ever been heaped upon the women 
who want to study medicine can exceed those once lavished on 
the presumptuous men who first forced their way into midwifery. 
As late as the seventeenth century, even at the time that Cham- 
berlain was inventing the forceps, the term "man midwife" was 
as much a term of reproach as that of "female physician" often 
is at the present day. The feeling of delicacy, permissible, even 
imperative in itself, was compelled to yield to the still more im- 

educated medical women would or would not be acceptable to the native 
ladies of India. It appears that the Maharajah of Punna, in Bundelcund, 
applied to Miss Beilby, a female medical missionary at Lucknow, to treat his 
wife, who had long been suffering ffom some painful internal ailment. Miss 
Beilby spent some weeks in attendance upon the Maharanee, and happily was 
able to effect a cure. 

When the time of her departure from Punna arrived, she was desired to 
present herself at the palace to take leave of her royal patient, on Wednes- 
day, the 13th April last. The Maha-Rani received her in her private room, 
and almost immediately dismissed all her attendants and ladies, so that she 
might be quite alone with her. The Maha-Rani then said she wished Miss 
Beilby to make her a solemn promise. Without knowing what it might in- 
volve, she was reluctant to do this, but at length the Maha-Rani said: "You 
are going to England, and I want you to tell our Queen and the Prince and 
Princess of Wales, and the men and women in England, what the women in 
the zenanas in India suffer when they are sick. Will you promise me to do 
this?" She explained that it was no social change in their condition she 
sought, but relief in their cruel sufferings. She charged Miss Beilby to give 
this message herself to the great Queen of England; not to send it through 
any other channel, but to take it herself, or her Majesty would think less of 
it. Miss Beilby represented to the Maha-Rani the difficulty she would have 
in getting access to the Queen — that with us it is not as in the East, that 
any one can go to the palace and lay a petition before the native sovereign. 
Besides, she told her she hardly knew what good it would do if she could do 
as she wished, and take her message to our Queen. The Queen could not 
make lady doctors, or order them to go out. It was not in the power of even 
the great Queen of England to do this. "But," said the Maha-Rani, "did 
you not tell me our Queen was good and gracious, that she never heard of 
sorrow or suffering without sending a message to say how sorry she was, and 
trying to help? Did you not show me a picture of a train falling into the sea, 
where a bridge broke, and did you not tell me how grieved our Queen was? 
Well, it was very sad those people should have been killed, but our condition 
is far worse; if you will only tell our Queen what we Indian women stiifer 
when we are sick, I am sure she will feel for us and try to help us." Miss 
Beilby felt she could no longer refuse to promise to convey this message, if 
possible. The Maha-Rani next bade her write it down at once (giving her 
pen, ink, and paper), lest she should forget it, and added, "Write it small, 
Doctor Miss Sahiba, for I want to put it in a locket, and you are to wear this 



376 Mary Putnam Jacobi 

perative claims of superior knowledge and capacity. If this has 
ever been accomplished, it is not doubtful that a legitimate feel- 
ing of delicacy — as that which makes many (not all) women dis- 
like to be treated for at least uterine diseases by a man — should, 
if once thoroughly reenforced by legitimate confidence in feminine 
skill, overpower the quite superficial ideas of delicacy in regard 

locket round your neck, till you see our great Queen and give it her yourself. 
You are not to send it through another." 

On reaching England, Miss Beilby communicated with some of the ladies 
about the Court, and on July 13, 1881, the Queen received her at Windsor 
Castle: 

Her Majesty listened to Miss Beilby's statement with great interest, asking 
mapy questions, and showing the deepest sympathy. Turning to her ladies, 
she said: "We had no idea it was as bad as this; something must be done 
for these poor creatures. " The Maha- Rani's locket with its message was given 
to the Queen, and Her Majesty entrusted Miss Beilby with a message in reply, 
which was intended for the Maha-Rani alone. But the Queen also gave Miss 
Beilby a message which might be given to every one with whom she spoke on 
the subject of the poor suffering Indian ladies: — "We should wish it gener- 
ally known that we sympathise with every effort made to relieve the suffering 
state of the women of India." 

We fear the Maha-Rani would after this be disappointed if she were told 
that three weeks later the medical women of Europe and America were ex- 
cluded from the International Medical Congress held in London last August, 
and that this exclusion was effected by the Queen's private physician, threat- 
ening the Congress with the loss of the Queen's name as patron if medical 
women were admitted. If this were anything more than an unauthorized ap- 
plication of the influence of royalty, it would be desirable for the Queen to re- 
member that it will not assist in relieving the suffering state of any of her 
Majesty's subjects to prevent their medical attendants from keeping au cou- 
rant with every advance in the knowledge of the complex aft of healing, and 
that it is not true that a very much less educated practitioner than those who 
desired to attend the Congress would be good enough for India. The fact of 
the skin of the patient being some shades darker than our own does not, as 
some people seem to imagine, simplify alike the physical organization and 
the abnormal conditions of the body, and if good medical women are wanted 
for India, they must receive as thorough a training as the best medical schools 
in England can give to men. The recent successes of the students from the 
London School of Medicine for Women in the Honor List of the London Uni- 
versity show that in this school, at any rate, the education given is good and 
thorough, and we hope her Majesty will in due time have the gratification of 
knowing that many medical women who have been trained there are at work 
in India and England in relieving the sufferings of her subjects. 

I am, Sir, your obedient servant, B. 

October 25. 



Shall Women Practice Medicine ? 377 

to co-education in medicine. We call these ideas superficial, 
for they only represent further misconceptions of the mental 
attitude of true medical students. The scope of the subjects 
studied is so immensely wider than the public can imagine; the 
mass of its details so much greater; the intellectual aspect so 
different; even the material conditions so changed,' that it is 
quite impossible for any one on the outside to judge of the form 
of feeling likely to be excited by the actual circumstances within.^ 
From all this series of misconceptions to which women are 
exposed in common with men physicians, and, for many reasons, 
more conspicuously than they, it would seem as if members of 
the profession should naturally be exempt. "It is an ill bird 
that fouls its own nest"; and it seems scarcely credible that any 
physician who loves and honors his calling as it deserves, should 
dare to pronounce it too coarse or too hardening a pursuit for 
women. Whenever this has been done, the argument is neces- 
sarily insincere. It is like the outcry of school-boys when their 
sisters beg to be allowed to play ball with them. "Go away! 
You are a girl! Girls don't play ball!" The school-boy is 
usually unable to enforce this brief but effective dictum by dis- 
sertations on the difference in the form of the clavicle between 
the male and the female, and consequent inferences as to the 
necessary inefficiency of girls in the art of pitching and catching. 
Grown to manhood, however, he learns to justify his opinions by 
formidable weights of erudition. These arguments vary from 
age to age, and to-day the fashionable one is drawn from natural 
history. By laborious researches into the comparative weight 
of the brain, 2 the strength of the muscles, the depth of the respira- 
tion, the powers of digestion, the richness of the blood, it is 
established that the typical woman, wherever she appears, must 
be an inferior animal to the typical man, wherever he may be 

» As in the dissection or post-mortem examination of dead bodies. 

' Not to interrupt the course of the text, we would here note that schemes 
of co-educa.tion which, in some shape, are really essential to the proper pro- 
fessional education of women, are always compatible with isolated instruc- 
tion on the very few special subjects where the association of young men 
and women students might be an embarrassment. But these topics occupy, 
after all, a very small part of medicine. 

3 It will not be forgotten that the latest tables of BischoflF give the pro- 
portions of the brain to the weight of the body as i to 36 for women, i to 
37.5 for men. 



378 Mary Putnam Jacobi 

found. The rapidity with which this abstract conclusion is 
applied to such a concrete problem as the capacity of women for 
the practice of medicine is amazing. Were the feat performed 
by feminine reasoners, it would, no doubt, be cited in proof of 
the hasty generalizations of the shallo